How To Use CPT Code 21445

CPT code 21445 describes the open treatment of mandibular or maxillary alveolar ridge fracture, which is a separate procedure used to repair damage from blunt force trauma. 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 21445?

CPT 21445 is a code used to describe the open treatment of mandibular or maxillary alveolar ridge fracture. This procedure is performed to repair damage caused by blunt force trauma to the thickened bone along the upper and lower jaw that holds the tooth sockets. The provider accesses the fracture through an incision and takes steps to realign the fracture and stabilize the jaw to promote proper healing.

2. Official Description

The official description of CPT code 21445 is: ‘Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure).’ This code specifically refers to the surgical repair of fractures in the alveolar ridge, which is the bone that supports the teeth.

3. Procedure

1. When performing the open treatment of a mandibular or maxillary alveolar ridge fracture, the provider begins by preparing the patient, ensuring they are appropriately prepped and anesthetized.
2. An incision is made along the jaw line to access the fractured area.
3. The provider then dissects through the fascia, which is the connective tissue that covers and supports deeper structures.
4. Once the fracture is visualized, the provider carefully realigns the broken bones back into their proper positioning.
5. To stabilize the jaw and promote healing, the provider may apply interdental wiring or arch bars. Arch bars are devices that follow the natural curve of the teeth and provide stabilization.
6. After the procedure, the provider irrigates the area, checks for bleeding, removes any instruments, and closes the incision.

4. Qualifying circumstances

CPT code 21445 is used for patients who have suffered a mandibular or maxillary alveolar ridge fracture due to blunt force trauma. This procedure is performed to repair the damage and restore proper alignment of the fractured bones. It is important to note that this code specifically refers to the open treatment of the fracture, indicating that a surgical approach is necessary.

5. When to use CPT code 21445

CPT code 21445 should be used when the provider performs an open treatment of a mandibular or maxillary alveolar ridge fracture. This code is appropriate when the fracture requires surgical intervention, such as realignment and stabilization using interdental wiring or arch bars. It is important to ensure that the procedure performed meets the specific criteria outlined in the code description.

6. Documentation requirements

When reporting CPT code 21445, the provider must document the following information:

• Patient’s diagnosis indicating the mandibular or maxillary alveolar ridge fracture
• Description of the procedure performed, including details of the incision, realignment, and use of interdental wiring or arch bars
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT code 21445, it is important to ensure that the procedure performed meets the specific criteria outlined in the code description. This code should not be reported if the procedure performed does not involve the open treatment of a mandibular or maxillary alveolar ridge fracture. Additionally, it is important to follow any specific billing guidelines provided by the payer or relevant coding guidelines.

8. Historical information

CPT code 21445 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient sustains a mandibular alveolar ridge fracture due to a sports injury. The provider performs an open treatment of the fracture, realigning the bones and stabilizing the jaw with arch bars.
2. A patient is involved in a car accident and suffers a maxillary alveolar ridge fracture. The provider performs an open treatment of the fracture, using interdental wiring to stabilize the jaw and promote proper healing.
3. A patient presents with a mandibular alveolar ridge fracture resulting from a fall. The provider performs an open treatment of the fracture, applying arch bars to stabilize the jaw and facilitate the healing process.
4. A patient experiences a maxillary alveolar ridge fracture due to a physical altercation. The provider performs an open treatment of the fracture, realigning the bones and using interdental wiring for stabilization.
5. A patient sustains a mandibular alveolar ridge fracture during a workplace accident. The provider performs an open treatment of the fracture, utilizing arch bars to stabilize the jaw and promote proper healing.