How To Use CPT Code 21423

CPT code 21423 describes the open treatment of a complicated fracture of the palatal or maxillary bone, 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 21423?

CPT code 21423 is used to describe the open treatment of a complicated fracture of the palatal or maxillary bone, specifically a LeFort I type fracture. This type of fracture typically occurs due to blunt force trauma and may involve comminuted fractures or those affecting the cranial nerve foramina. The procedure involves multiple approaches to access and repair the fracture.

2. Official Description

The official description of CPT code 21423 is: ‘Open treatment of palatal or maxillary fracture (LeFort I type) complicated (comminuted or involving cranial nerve foramina), multiple approaches.’

3. Procedure

The open treatment of a complicated palatal or maxillary fracture involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes gingivolabial incisions through the oral mucosa, extending from one molar region to the other, to expose the fracture site.
3. Additional subciliary or transconjunctival incisions may be made to better visualize the fracture and any involved cranial nerves passing through the foramina.
4. 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.
5. Miniplates are shaped to fit the fractured area and secured with screws to stabilize the fracture.
6. The area is irrigated, bleeding is checked, instruments are removed, and the incisions are closed.

4. Qualifying circumstances

CPT code 21423 is used for the open treatment of a complicated palatal or maxillary fracture, specifically a LeFort I type fracture. The fracture may be comminuted or involve the cranial nerve foramina. The procedure requires multiple approaches to adequately access and repair the fracture.

5. When to use CPT code 21423

CPT code 21423 should be used when a provider performs the open treatment of a complicated palatal or maxillary fracture, specifically a LeFort I type fracture. This code is appropriate when the fracture is comminuted or involves the cranial nerve foramina, and multiple approaches are required to access and repair the fracture.

6. Documentation requirements

To support a claim for CPT code 21423, the provider must document the following information:

• Diagnosis of a complicated palatal or maxillary fracture, specifically a LeFort I type fracture
• Description of the fracture, including whether it is comminuted or involves the cranial nerve foramina
• Details of the multiple approaches used to access and repair the fracture
• Procedure start and end times
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 21423, ensure that the procedure performed meets the criteria for a complicated palatal or maxillary fracture, specifically a LeFort I type fracture. The documentation should clearly indicate the use of multiple approaches to access and repair the fracture. It is important to follow any specific billing guidelines provided by the payer or Medicare.

8. Historical information

CPT code 21423 was added to the Current Procedural Terminology system on January 1, 1993. It was initially removed from the Inpatient Only (IPO) list in 2017 but was later added back to the list in 2022.

9. Similar codes to CPT 21423

There are several similar codes to CPT code 21423 that describe different procedures for the treatment of fractures and dislocations on the head. Some similar codes include:

• CPT 21315: Open treatment of nasal bone fracture
• CPT 21450: Closed treatment of midface fracture (LeFort II type)
• CPT 21455: Open treatment of midface fracture (LeFort II type)
• CPT 21461: Open treatment of midface fracture (LeFort III type)
• CPT 21470: Closed treatment of zygomatic fracture

9. Examples

1. A patient sustains a complicated palatal fracture due to a motor vehicle accident. The provider performs an open treatment of the fracture using multiple approaches to access and repair the fracture.
2. An individual experiences a maxillary fracture involving the cranial nerve foramina as a result of a sports injury. The provider performs an open treatment of the fracture, utilizing gingivolabial and subciliary incisions to access and repair the fracture.
3. A patient presents with a comminuted LeFort I type fracture of the palatal bone. The provider performs an open treatment of the fracture, employing multiple approaches to adequately address the complexity of the fracture.
4. An individual suffers a complicated maxillary fracture with involvement of the cranial nerve foramina due to a fall. The provider performs an open treatment of the fracture, utilizing transconjunctival and gingivolabial incisions to access and repair the fracture.
5. A patient sustains a comminuted palatal fracture as a result of a physical assault. The provider performs an open treatment of the fracture, employing multiple approaches to ensure proper alignment and stabilization of the fracture.
6. An individual experiences a LeFort I type fracture involving the cranial nerve foramina due to a workplace accident. The provider performs an open treatment of the fracture, utilizing subciliary and gingivolabial incisions to access and repair the fracture.
7. A patient presents with a complicated maxillary fracture, comminuted and involving the cranial nerve foramina, following a bicycle accident. The provider performs an open treatment of the fracture, employing multiple approaches to address the complexity of the fracture.