How To Use CPT Code 21336

CPT code 21336 describes the open treatment of a nasal septal fracture, with or without stabilization. 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 21336?

CPT 21336 is used to describe the open treatment of a nasal septal fracture, with or without stabilization. This procedure involves the reduction or realignment of a fractured nasal septum through a nasal incision. The goal of this treatment is to restore both functionality and appearance to the nose. The provider may use sutures in the septum to hold it in place while it heals.

2. Official Description

The official description of CPT code 21336 is: ‘Open treatment of nasal septal fracture, with or without stabilization.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision over the fracture and into the cartilage to visualize the septum.
3. Surgical tools are used to move the septum, as well as any accompanying fractured cartilage or tissue, into the appropriate positions.
4. If necessary, sutures are placed into the septum to hold it in position.
5. The incision is closed in layers.

4. Qualifying circumstances

CPT 21336 is performed when a patient has a nasal septal fracture that requires open treatment. This procedure is typically reserved for cases where the fracture is severe or complex, and other treatment options, such as closed reduction, are not feasible. The provider must assess the patient’s condition and determine that open treatment is necessary to restore functionality and appearance to the nose.

5. When to use CPT code 21336

CPT code 21336 should be used when the provider performs open treatment of a nasal septal fracture, with or without stabilization. This code is appropriate when the fracture requires surgical intervention and the provider makes an incision to access and realign the septum. It should not be used for cases where closed reduction or other non-surgical methods are sufficient.

6. Documentation requirements

To support a claim for CPT 21336, the provider must document the following information:

• Patient’s diagnosis of a nasal septal fracture
• Reason for choosing open treatment over other methods
• Description of the procedure performed, including details of the incision, reduction, and stabilization techniques
• Any complications or additional procedures performed
• Post-operative instructions and follow-up plans
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21336, ensure that the procedure meets the criteria for open treatment of a nasal septal fracture. The provider should document the necessity of open treatment and the specific techniques used during the procedure. It is important to follow the guidelines set forth by the payer and use appropriate modifiers if necessary.

8. Historical information

CPT 21336 was added to the Current Procedural Terminology system on January 1, 1993. There have been no updates to the code since its addition.

9. Examples

1. A patient with a severe nasal septal fracture undergoes open treatment with stabilization using sutures.
2. A provider performs open treatment of a nasal septal fracture in a patient who has previously undergone unsuccessful closed reduction.
3. A patient with a complex nasal septal fracture undergoes open treatment to restore both functionality and appearance to the nose.
4. A provider performs open treatment of a nasal septal fracture in a patient who has experienced significant trauma to the nose.
5. A patient with a nasal septal fracture that is causing breathing difficulties undergoes open treatment to improve nasal airflow.
6. A provider performs open treatment of a nasal septal fracture in a patient who desires cosmetic improvement of the nose.
7. A patient with a nasal septal fracture undergoes open treatment to prevent long-term complications, such as nasal obstruction or deformity.
8. A provider performs open treatment of a nasal septal fracture in a patient who has failed to respond to conservative management.
9. A patient with a nasal septal fracture undergoes open treatment to correct a deviated septum and improve nasal symmetry.
10. A provider performs open treatment of a nasal septal fracture in a patient who requires surgical intervention due to the complexity of the fracture.