How To Use CPT Code 21440

CPT 21440 describes the closed treatment of mandibular or maxillary alveolar ridge fracture, which is a separate procedure. 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 21440?

CPT 21440 is used to describe the closed treatment of mandibular or maxillary alveolar ridge fracture. This code is specifically for the repair of fractures in the thickened bone along the upper and lower jaw that holds the tooth sockets. The procedure involves manipulation without an incision.

2. Official Description

The official description of CPT code 21440 is: ‘Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure).’ This code represents the manipulation and stabilization of the fractured jaw using interdental wiring or arch bars.

3. Procedure

During the procedure for CPT 21440, the provider first examines the patient after appropriate preparation and anesthesia. The provider then uses manipulation techniques to realign the fractured bone back into its proper position. To stabilize the jaw and promote healing, interdental wiring or arch bars are applied.

4. Qualifying circumstances

CPT 21440 is used for patients who have fractures in the mandibular or maxillary alveolar ridge. These fractures are typically caused by blunt force trauma. The procedure is performed by a qualified healthcare professional who is trained in the treatment of these fractures. The patient must meet the criteria for the specific fracture and be in need of closed treatment without the need for an incision.

5. When to use CPT code 21440

CPT code 21440 should be used when a provider performs the closed treatment of a mandibular or maxillary alveolar ridge fracture as a separate procedure. It should not be reported if the fracture repair is performed during another, more extensive surgery. In such cases, the code for the primary procedure should be used instead.

6. Documentation requirements

To support a claim for CPT 21440, the provider must document the following information:

• Patient’s diagnosis of mandibular or maxillary alveolar ridge fracture
• Details of the closed treatment procedure performed
• Date of the procedure
• Any additional procedures or treatments performed during the same encounter
• Any complications or unusual findings
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21440, ensure that the procedure meets the criteria for a separate procedure and is not performed during another surgery. If the provider performs a stabilization procedure with wiring prior to a scheduled surgery, an E/M code may be reported to cover the provider’s time during the fixation. It is important to review the documentation and discuss with the provider to determine the appropriate way to report the procedure.

8. Historical information

CPT 21440 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient presents with a mandibular alveolar ridge fracture due to a fall. The provider performs closed treatment using interdental wiring to stabilize the fracture.
2. A patient sustains a maxillary alveolar ridge fracture during a sports-related injury. The provider manipulates the fracture back into alignment and applies arch bars for stabilization.
3. A patient is involved in a car accident and fractures both the mandibular and maxillary alveolar ridges. The provider performs closed treatment on both fractures using interdental wiring.
4. A patient presents with a mandibular alveolar ridge fracture resulting from a physical altercation. The provider performs closed treatment using arch bars to stabilize the fracture.
5. A patient sustains a maxillary alveolar ridge fracture during a fall. The provider manipulates the fracture and applies interdental wiring for stabilization.
6. A patient fractures their mandibular alveolar ridge while playing contact sports. The provider performs closed treatment using arch bars to stabilize the fracture.
7. A patient is involved in a motorcycle accident and fractures their maxillary alveolar ridge. The provider manipulates the fracture and applies interdental wiring for stabilization.
8. A patient sustains a mandibular alveolar ridge fracture during a physical assault. The provider performs closed treatment using arch bars to stabilize the fracture.
9. A patient presents with a maxillary alveolar ridge fracture resulting from a fall. The provider manipulates the fracture back into alignment and applies interdental wiring for stabilization.
10. A patient fractures their mandibular alveolar ridge while playing recreational sports. The provider performs closed treatment using arch bars to stabilize the fracture.