How To Use CPT Code 21243

CPT code 21243 describes the procedure of arthroplasty, specifically the replacement of the temporomandibular joint (TMJ) with a prosthetic joint. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21243?

CPT 21243 is used to describe the surgical procedure of arthroplasty, specifically the replacement of the temporomandibular joint (TMJ) with a prosthetic joint. The TMJ is the hinge structure that connects the lower jaw to the temporal bone of the skull. This procedure aims to improve the function of the jaw by replacing the damaged joint with an artificial joint.

2. Official Description

The official description of CPT code 21243 is: ‘Arthroplasty, temporomandibular joint, with prosthetic joint replacement.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision along the ear and another incision along the jawline to expose the fascial tissue layer and examine the TMJ capsule.
3. Microdissection is used to excise the condyle (ball of the joint) on both sides, as well as both fossae (joint sockets).
4. The damaged joint on each side of the jaw is replaced with a prosthetic joint, typically made of titanium.
5. The provider ensures proper fit and function of the prosthetic joint.
6. The area is irrigated, checked for bleeding, any instruments are removed, and the incision is closed.

4. Qualifying circumstances

CPT 21243 is performed on patients who require the replacement of the temporomandibular joint due to dysfunction or damage. The procedure is typically performed by a qualified healthcare professional who specializes in oral and maxillofacial surgery. The patient must have a documented need for the arthroplasty procedure, and other conservative treatment options should have been exhausted before considering joint replacement.

5. When to use CPT code 21243

CPT code 21243 should be used when a provider performs arthroplasty of the temporomandibular joint with prosthetic joint replacement. This code is appropriate when the procedure is performed to improve the function of the jaw in patients with TMJ dysfunction or damage. It is important to ensure that the documentation supports the medical necessity of the procedure and that other treatment options have been considered and deemed ineffective.

6. Documentation requirements

To support a claim for CPT 21243, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for temporomandibular joint replacement
• Details of the procedure, including the incisions made, excision of the condyle and fossae, and placement of the prosthetic joint
• Confirmation of proper fit and function of the prosthetic joint
• Documentation of any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 21243, ensure that the procedure meets the criteria for medical necessity and is performed by a qualified healthcare professional. It is important to follow the specific guidelines provided by the payer and use the appropriate modifiers if required. It is also essential to document any additional procedures or services performed during the same encounter to avoid billing conflicts.

8. Historical information

CPT 21243 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with severe TMJ dysfunction undergoes arthroplasty of the temporomandibular joint with prosthetic joint replacement to improve jaw function.
2. A patient with a history of trauma to the jaw requires arthroplasty of the temporomandibular joint with prosthetic joint replacement to restore normal jaw movement.
3. A patient with chronic TMJ pain undergoes arthroplasty of the temporomandibular joint with prosthetic joint replacement to alleviate symptoms and improve quality of life.
4. A patient with congenital TMJ abnormalities undergoes arthroplasty of the temporomandibular joint with prosthetic joint replacement to correct the structural issues and improve jaw function.
5. A patient with TMJ arthritis undergoes arthroplasty of the temporomandibular joint with prosthetic joint replacement to relieve pain and improve jaw mobility.
6. A patient with a failed previous TMJ surgery requires arthroplasty of the temporomandibular joint with prosthetic joint replacement to restore proper joint function.
7. A patient with TMJ ankylosis undergoes arthroplasty of the temporomandibular joint with prosthetic joint replacement to release the joint and improve jaw movement.
8. A patient with TMJ disc displacement undergoes arthroplasty of the temporomandibular joint with prosthetic joint replacement to correct the alignment and improve jaw function.
9. A patient with TMJ degeneration undergoes arthroplasty of the temporomandibular joint with prosthetic joint replacement to restore normal joint function and alleviate pain.
10. A patient with TMJ malocclusion undergoes arthroplasty of the temporomandibular joint with prosthetic joint replacement to correct the bite and improve jaw alignment.