How To Use CPT Code 21435

CPT 21435 describes the open treatment of craniofacial separation (LeFort III type) complicated, utilizing internal and/or external fixation techniques. 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 21435?

CPT 21435 is used to describe the open treatment of craniofacial separation, specifically the LeFort III type, which involves the separation of the cranium or skull from the facial bones. This procedure is performed to repair injuries to the nasal bridge or upper jaw following severe trauma to the face. The provider accesses the fracture through an incision and applies internal and/or external fixation techniques to hold the fracture in place as it heals.

2. Official Description

The official description of CPT code 21435 is: ‘Open treatment of craniofacial separation (LeFort III type) complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation).’

3. Procedure

The procedure for CPT 21435 involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider places arch bars on the upper and lower teeth to provide internal fixation of the fracture.
3. Wire is used to secure the arch bars to the teeth and confirm intermaxillary fixation.
4. A coronal incision is made through the scalp to expose the fractured bones.
5. A scalp flap is reflected down to just above the cheekbone to expose the zygomatic arch and visualize the fracture.
6. Subciliary incisions below the eyebrows or transconjunctival incisions across the conjunctiva may be made to better visualize the fracture.
7. The provider checks for any involved cranial nerves as they pass through the foramina in the skull.
8. Bilateral buccal sulcus incisions are made and dissection is done down to the piriform aperture and orbital rims.
9. The provider reduces the fractured bones and applies internal fixation using plates, screws, and/or wires.
10. An external fixation device like a head cap or halo may be attached to the internal fixation to further stabilize the fracture.
11. The area is irrigated, bleeding is checked, instruments are removed, and the incisions are closed.

4. Qualifying circumstances

CPT 21435 is performed on patients with craniofacial separation, specifically the LeFort III type, resulting from severe trauma to the face. The procedure is used to repair injuries to the nasal bridge or upper jaw. The use of internal and/or external fixation techniques is necessary to stabilize the fracture and promote proper healing.

5. When to use CPT code 21435

CPT code 21435 should be used when the provider performs the open treatment of craniofacial separation (LeFort III type) complicated, utilizing internal and/or external fixation techniques. It is important to ensure that the procedure performed matches the description provided by the code.

6. Documentation requirements

To support a claim for CPT 21435, the provider must document the following information:

• Patient’s diagnosis of craniofacial separation (LeFort III type)
• Details of the procedure performed, including the use of internal and/or external fixation techniques
• Incision site and approach
• Specific fixation devices used, such as head cap, halo device, or intermaxillary fixation
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 21435, it is important to ensure that the procedure performed matches the description provided by the code. The use of internal and/or external fixation techniques should be documented in the medical record. It is also important to follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 21435 was added to the Current Procedural Terminology system on January 1, 1990. It was initially listed as an inpatient-only (IPO) procedure, but was later removed from the IPO list in 2021. However, it was added back to the IPO list in 2022.

9. Similar codes to CPT 21435

There are several similar codes to CPT 21435 that describe other fracture and/or dislocation procedures on the head. These include:

• CPT 21315: Open treatment of nasal bone fracture
• CPT 21450: Open treatment of zygomatic fracture, except isolated zygomatic arch fracture
• CPT 21452: Open treatment of zygomatic arch fracture, including elevation of depressed arch
• CPT 21462: Open treatment of orbital floor fracture, including exploration, when performed
• CPT 21480: Open treatment of mandibular fracture, without fixation

9. Examples

1. A patient sustains severe facial trauma resulting in craniofacial separation (LeFort III type). The provider performs an open treatment using internal fixation techniques, including plates and screws, to stabilize the fracture.
2. A patient presents with a nasal bridge fracture following a car accident. The provider performs an open treatment using external fixation techniques, including a head cap, to hold the fracture in place during the healing process.
3. A patient suffers a facial injury during a sports accident, resulting in craniofacial separation (LeFort III type). The provider performs an open treatment using a combination of internal and external fixation techniques, including plates, screws, and a halo device, to ensure proper alignment and stability of the fracture.
4. A patient undergoes a surgical procedure to repair a craniofacial separation (LeFort III type) resulting from a fall. The provider utilizes intermaxillary fixation, along with internal fixation techniques, to immobilize the fracture and promote healing.
5. A patient is involved in a physical altercation, resulting in a severe facial fracture. The provider performs an open treatment using internal fixation techniques, including wires and plates, to realign the fractured bones and restore facial symmetry.