How To Use CPT Code 21385

CPT 21385 describes the open treatment of an orbital floor blowout fracture using a transantral approach, specifically the Caldwell-Luc type operation. 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 21385?

CPT 21385 is used to describe the open treatment of an orbital floor blowout fracture using a transantral approach, known as the Caldwell-Luc type operation. This procedure is performed to repair the floor of the orbit, which holds the eyes, and restore function and appearance to the face after a blowout fracture caused by blunt force trauma.

2. Official Description

The official description of CPT code 21385 is: ‘Open treatment of orbital floor blowout fracture transantral approach (Caldwell-Luc type operation).’ This procedure involves accessing the orbital floor through an incision made in the mouth.

3. Procedure

During the procedure described by CPT 21385, the healthcare provider follows these steps:

1. The patient is appropriately prepped and anesthetized.
2. An incision is made inferior to, or behind, the buccogingival sulcus, which is the space between the gum and cheek.
3. A wide mucosal band is exposed.
4. The anterior maxillary wall is stripped of its periosteum using a periosteal elevator.
5. A Caldwell Luc antrostomy is created, which is an opening through the maxillary sinus cavity.
6. Surgical tools are used to increase the diameter of the antrostomy, providing access to the orbital floor.
7. The mucosa from the maxillary antrum is stripped, and the orbital fracture is repaired.
8. The area is irrigated, checked for bleeding, and any instruments are removed.
9. The incisions are closed.

4. Qualifying circumstances

CPT 21385 is performed on patients who have sustained a blowout fracture of the orbital floor due to blunt force trauma. This procedure is intended to restore function and appearance to the face. It is important to note that the procedure must be performed using a transantral approach, specifically the Caldwell-Luc type operation.

5. When to use CPT code 21385

CPT code 21385 should be used when the healthcare provider performs an open treatment of an orbital floor blowout fracture using a transantral approach, specifically the Caldwell-Luc type operation. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 21385, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the presence of an orbital floor blowout fracture
• Description of the procedure performed, including the transantral approach and the use of the Caldwell-Luc type operation
• Date of the procedure
• Details of the surgical technique used
• Any complications encountered during the procedure
• Post-operative care instructions
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 21385, it is important to ensure that the procedure meets the specific criteria outlined in the code description. There are no specific billing guidelines or modifiers mentioned for this code. However, it is essential to follow the documentation requirements and provide accurate and detailed information to support the claim.

8. Historical information

CPT 21385 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. Similar codes to CPT 21385

While there are no similar codes specifically mentioned for CPT 21385, there are other codes within the range of Fracture and/or Dislocation Procedures on the Head (21315-21497) that may be relevant for different types of orbital fractures or procedures.

9. Examples

1. A patient sustains a blowout fracture of the orbital floor due to a sports-related injury. The healthcare provider performs an open treatment using a transantral approach, specifically the Caldwell-Luc type operation, to repair the fracture and restore function and appearance to the face.
2. Following a motor vehicle accident, a patient presents with an orbital floor blowout fracture. The healthcare provider performs an open treatment using a transantral approach, specifically the Caldwell-Luc type operation, to repair the fracture and restore function and appearance to the face.
3. A patient experiences a traumatic injury resulting in an orbital floor blowout fracture. The healthcare provider performs an open treatment using a transantral approach, specifically the Caldwell-Luc type operation, to repair the fracture and restore function and appearance to the face.
4. Due to a physical altercation, a patient suffers an orbital floor blowout fracture. The healthcare provider performs an open treatment using a transantral approach, specifically the Caldwell-Luc type operation, to repair the fracture and restore function and appearance to the face.
5. Following a fall, a patient presents with an orbital floor blowout fracture. The healthcare provider performs an open treatment using a transantral approach, specifically the Caldwell-Luc type operation, to repair the fracture and restore function and appearance to the face.
6. A patient sustains an orbital floor blowout fracture during a sporting event. The healthcare provider performs an open treatment using a transantral approach, specifically the Caldwell-Luc type operation, to repair the fracture and restore function and appearance to the face.
7. Due to a workplace accident, a patient suffers an orbital floor blowout fracture. The healthcare provider performs an open treatment using a transantral approach, specifically the Caldwell-Luc type operation, to repair the fracture and restore function and appearance to the face.
8. A patient is involved in a physical altercation resulting in an orbital floor blowout fracture. The healthcare provider performs an open treatment using a transantral approach, specifically the Caldwell-Luc type operation, to repair the fracture and restore function and appearance to the face.