How To Use CPT Code 21348

CPT 21348 describes the open treatment of a nasomaxillary complex fracture (LeFort II type) with bone grafting, including obtaining the graft. 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 21348?

CPT 21348 is used to describe the open treatment of a nasomaxillary complex fracture, specifically the LeFort II type. This procedure involves repairing the bones of the nose and maxilla (jawbone) to restore both function and appearance. It includes the use of bone grafting, which may involve obtaining graft material from the patient’s own body or using artificial, synthetic, or natural substitutes.

2. Official Description

The official description of CPT code 21348 is: ‘Open treatment of nasomaxillary complex fracture (LeFort II type) with bone grafting (includes obtaining graft).’

3. Procedure

During the procedure for CPT 21348, the patient is appropriately prepped and anesthetized. The provider begins by making an incision over the chosen site for harvesting a bone graft, typically from the hip bone. The necessary amount of autograft is obtained, and the wound is closed. Subsequently, sublabial incisions are made to expose the maxillary (upper jaw) bone. The provider then realigns the fractured segments, stabilizing the pyramidal-shaped free maxillary segment to the zygoma (cheekbone). To fill in the defect, bone graft material is used. A fixation plate may be placed in the zygomaticomaxillary buttress and secured with screws. Alternatively, the provider may choose to use steel wiring to secure the reduced fracture, attaching it to the dental ridge. The area is irrigated, checked for bleeding, instruments are removed, and the incision is closed.

4. Qualifying circumstances

CPT 21348 is performed for patients with a nasomaxillary complex fracture of the LeFort II type. This type of fracture involves the bones of the nose and maxilla, resulting in a specific pattern of injury. The procedure is intended to restore function and appearance in these patients. Bone grafting may be necessary to fill in defects caused by the fracture. The use of autograft or other graft materials is determined by the provider based on the patient’s specific needs.

5. When to use CPT code 21348

CPT code 21348 should be used when the provider performs an open treatment for a nasomaxillary complex fracture of the LeFort II type and includes bone grafting, including obtaining the graft. It is important to accurately document the specific fracture type and the use of bone grafting in the medical record to support the use of this code.

6. Documentation requirements

To support a claim for CPT 21348, the provider must document the following information:

• Specific diagnosis of a nasomaxillary complex fracture (LeFort II type)
• Description of the procedure performed, including the use of bone grafting and obtaining the graft
• Details of the incisions made and the specific bones involved
• Method of stabilization used, such as fixation plate or steel wiring
• Type of graft material used, whether autograft or other substitutes
• Any additional procedures performed during the same surgical session
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21348, ensure that the procedure performed matches the description of the code. It is important to accurately document the use of bone grafting and obtaining the graft in the medical record. Modifier 80, Assistant Surgeon, may be appended if a surgical assistant is involved in the procedure. It is recommended to check with the insurer regarding the separate billing of a surgical assistant.

8. Historical information

CPT 21348 was added to the Current Procedural Terminology system on January 1, 1993. It was initially not listed as an Inpatient Only (IPO) procedure. However, in 2017, it was added to the IPO list. In 2021, it was removed from the IPO list, but in 2022, it was added back to the IPO list.

9. Similar codes to CPT 21348

There are several similar codes to CPT 21348 that describe other fracture and/or dislocation procedures on the head. These include CPT codes 21315-21497. Each code within this range represents a specific procedure for the treatment of fractures and dislocations in different areas of the head.

9. Examples

1. A patient sustains a LeFort II type fracture involving the nasomaxillary complex. The provider performs an open treatment, realigning the fractured segments and stabilizing the maxillary segment to the zygoma. Bone grafting is performed to fill in the defect caused by the fracture.
2. Another patient presents with a nasomaxillary complex fracture of the LeFort II type. The provider performs an open treatment, using bone grafting to restore the fractured bones. The graft material is obtained from the patient’s own body.
3. A third patient requires an open treatment for a LeFort II type fracture involving the nasomaxillary complex. The provider performs bone grafting, using a synthetic substitute to fill in the defect caused by the fracture.
4. Yet another patient sustains a nasomaxillary complex fracture of the LeFort II type. The provider performs an open treatment, utilizing bone grafting with an artificial substitute to restore the fractured bones.
5. A patient presents with a LeFort II type fracture of the nasomaxillary complex. The provider performs an open treatment, using bone grafting with a natural substitute to fill in the defect caused by the fracture.
6. Another patient requires an open treatment for a nasomaxillary complex fracture of the LeFort II type. The provider performs bone grafting, obtaining autograft from the patient’s hip bone to restore the fractured bones.
7. A third patient sustains a LeFort II type fracture involving the nasomaxillary complex. The provider performs an open treatment, using bone grafting with an artificial substitute to fill in the defect caused by the fracture.
8. Yet another patient presents with a nasomaxillary complex fracture of the LeFort II type. The provider performs an open treatment, utilizing bone grafting with a natural substitute to restore the fractured bones.