How To Use CPT Code 21436

CPT 21436 describes the open treatment of craniofacial separation (LeFort III type) complicated, multiple surgical approaches, internal fixation, with bone grafting. 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 21436?

CPT 21436 is a code used to describe the open treatment of craniofacial separation, specifically the LeFort III type. This procedure involves multiple surgical approaches, internal fixation, and bone grafting. It is performed to repair injuries to the nasal bridge or upper jaw resulting from severe trauma to the face.

2. Official Description

The official description of CPT code 21436 is: ‘Open treatment of craniofacial separation (LeFort III type) complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft).’

3. Procedure

The procedure for CPT 21436 involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. An incision is made over the site chosen for harvesting a bone graft, typically the hip bone.
3. The provider removes sufficient autograft from the chosen site and closes the wound.
4. Arch bars are placed on the upper and lower teeth, and intermaxillary fixation is confirmed.
5. A coronal incision is made to expose the fractured bones.
6. A scalp flap is reflected down to just above the zygoma to expose the zygomatic arch and visualize the fracture.
7. Transconjunctival and bilateral buccal sulcus incisions are made to dissect down to the piriform aperture, orbital rims, and posterior zygomaticomaxillary buttresses.
8. The bone graft is sized to fit the defect and secured to the bone.
9. The fractured bones are reduced and stabilized using plates, screws, and/or wires.
10. The area is irrigated, checked for bleeding, instruments are removed, and the incisions are closed.

4. Qualifying circumstances

CPT 21436 is performed on patients with a complicated facial fracture resulting in separation of the cranium from the facial bones. It is specifically used to repair injuries to the nasal bridge or upper jaw following severe trauma to the face. The procedure involves multiple surgical approaches, internal fixation, and bone grafting.

5. When to use CPT code 21436

CPT code 21436 should be used when performing the open treatment of craniofacial separation of the LeFort III type. It is important to ensure that the procedure involves multiple surgical approaches, internal fixation, and bone grafting. If any of these components are not performed, a different code should be used to accurately describe the procedure.

6. Documentation requirements

To support a claim for CPT 21436, the following documentation is required:

• Patient’s medical history and diagnosis
• Details of the procedure performed, including the specific surgical approaches used
• Description of the bone grafting process, including the source of the graft
• Date and duration of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21436, it is important to ensure that the procedure meets the criteria outlined in the code description. The procedure should involve the open treatment of craniofacial separation of the LeFort III type, with multiple surgical approaches, internal fixation, and bone grafting. It is also important to follow any specific billing guidelines provided by insurance carriers or payers.

8. Historical information

CPT code 21436 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 21436

There are several similar codes to CPT 21436 that describe procedures for the treatment of facial fractures and craniofacial injuries. Some examples include:

• CPT 21440: Open treatment of zygomatic fracture, including internal fixation
• CPT 21451: Open treatment of mandibular condylar fracture, includes internal fixation
• CPT 21462: Open treatment of orbital floor fracture, including internal fixation
• CPT 21480: Open treatment of frontal sinus fracture, including internal fixation
• CPT 21490: Open treatment of nasoethmoid fracture, including internal fixation

9. Examples

1. A patient sustains a severe facial fracture resulting in craniofacial separation of the LeFort III type. The provider performs an open treatment procedure, utilizing multiple surgical approaches, internal fixation, and bone grafting to repair the injury.
2. Following a traumatic accident, a patient presents with a nasal bridge and upper jaw injury. The provider performs the open treatment of craniofacial separation, utilizing multiple surgical approaches, internal fixation, and bone grafting to restore the facial structure.
3. A patient undergoes a complex facial reconstruction procedure due to a severe facial fracture. The provider performs the open treatment of craniofacial separation, utilizing multiple surgical approaches, internal fixation, and bone grafting to repair the injury and restore facial aesthetics.
4. After sustaining a severe facial injury, a patient requires extensive surgical intervention. The provider performs the open treatment of craniofacial separation, utilizing multiple surgical approaches, internal fixation, and bone grafting to reconstruct the damaged facial bones.
5. A patient presents with a craniofacial separation of the LeFort III type following a traumatic incident. The provider performs the open treatment procedure, utilizing multiple surgical approaches, internal fixation, and bone grafting to repair the injury and restore facial function.
6. Following a severe facial trauma, a patient requires surgical intervention to repair the craniofacial separation. The provider performs the open treatment procedure, utilizing multiple surgical approaches, internal fixation, and bone grafting to restore the patient’s facial structure and function.