How To Use CPT Code 21422

CPT code 21422 describes the open treatment of a palatal or maxillary fracture, specifically a LeFort I type fracture. 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 21422?

CPT 21422 is used to describe the open treatment of a palatal or maxillary fracture, specifically a LeFort I type fracture. This type of fracture typically occurs due to blunt force trauma and involves the roof of the mouth or upper jaw bone. The procedure involves making an incision in the mouth to access the fracture and then using miniplates and screws to secure the fractured area.

2. Official Description

The official description of CPT code 21422 is: ‘Open treatment of palatal or maxillary fracture (LeFort I type).’ This code is specifically for the treatment of a LeFort I type fracture, which involves a horizontal fracture through the maxilla or upper jaw.

3. Procedure

The procedure for CPT 21422 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes gingivolabial incisions through the oral mucosa from one molar region to the other, exposing the fracture lines and other relevant structures.
3. A periosteal elevator is used to separate the periosteum and expose the fracture lines, nasomaxillary and zygomaticomaxillary buttresses, piriform aperture, and premaxilla and nasal spine.
4. Miniplates are shaped to fit the fractured area and are secured with screws.
5. The area is irrigated, checked for bleeding, and any instruments are removed.
6. The incision is closed.

4. Qualifying circumstances

CPT 21422 is used for the open treatment of a palatal or maxillary fracture, specifically a LeFort I type fracture. This code is applicable when the provider performs the procedure to treat a fracture of the roof of the mouth or upper jaw bone caused by blunt force trauma. It is important to note that codes specifying a LeFort I type fracture are not exclusively reserved for textbook LeFort I fractures, and the code should be selected based on the type of repair performed.

5. When to use CPT code 21422

CPT code 21422 should be used when the provider performs the open treatment of a palatal or maxillary fracture, specifically a LeFort I type fracture. This code is appropriate when the procedure involves making an incision in the mouth to access the fracture and using miniplates and screws to secure the fractured area. It is important to accurately document the type of fracture and the specific procedure performed to support the use of this code.

6. Documentation requirements

To support a claim for CPT code 21422, the provider must document the following information:

• Patient’s diagnosis indicating the presence of a palatal or maxillary fracture
• Description of the procedure performed, including the specific steps taken to treat the fracture
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT code 21422, ensure that the procedure performed meets the criteria for open treatment of a palatal or maxillary fracture, specifically a LeFort I type fracture. It is important to accurately document the procedure and any associated diagnoses to support the use of this code. Additionally, consider any specific billing guidelines provided by payers or coding guidelines to ensure proper reimbursement.

8. Historical information

CPT code 21422 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been several historical changes to the code, including being added and removed from the Inpatient Only (IPO) list by Medicare. It is important to stay updated on any changes or updates to ensure accurate coding and billing.

9. Examples

Here are some examples of cases where CPT code 21422 may be billed:

1. A patient sustains a LeFort I type fracture due to a car accident and undergoes open treatment of the fracture.
2. A patient experiences a sports-related injury resulting in a palatal fracture, and the provider performs open treatment to repair the fracture.
3. A patient presents with a maxillary fracture caused by a fall and undergoes open treatment to correct the fracture.
4. A patient sustains a LeFort I type fracture during an assault and undergoes open treatment to repair the fracture.
5. A patient undergoes open treatment of a palatal fracture following a workplace accident.
6. A patient sustains a maxillary fracture due to a recreational activity and undergoes open treatment to repair the fracture.
7. A patient presents with a LeFort I type fracture resulting from a sports-related injury, and the provider performs open treatment to correct the fracture.
8. A patient sustains a palatal fracture during a physical altercation and undergoes open treatment to repair the fracture.
9. A patient undergoes open treatment of a maxillary fracture caused by a fall.
10. A patient presents with a LeFort I type fracture resulting from a motor vehicle accident and undergoes open treatment to repair the fracture.