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The procedure described by CPT® Code 21385 involves the open treatment of an orbital floor blowout fracture using a transantral approach, specifically the Caldwell-Luc type operation. This surgical intervention is aimed at repairing the orbital floor, which is a critical structure that supports the eye and is often compromised in cases of mid-facial trauma. An orbital floor blowout fracture can lead to significant complications, including entrapment of extraocular muscles, which can impair eye movement, as well as aesthetic deformities of the face. The transantral approach allows the surgeon to access the orbital floor through the mouth, minimizing external scarring while providing direct access to the fracture site. The procedure involves several meticulous steps, including the retraction of the upper lip to expose the gingivobuccal sulcus, making a horizontal incision, and elevating the periosteum to access the maxillary sinus. This approach not only facilitates the repair of the fracture but also ensures that any herniated orbital contents are properly managed, restoring both the anatomical integrity and functional capabilities of the eye. The use of an implant may be necessary if there is a bony deficit, and careful attention is given to hemostasis before closing the incision with sutures, ensuring optimal recovery and outcomes for the patient.
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The open treatment of an orbital floor blowout fracture using a transantral approach is indicated for patients who present with specific symptoms and conditions associated with this type of injury. These indications include:
The open treatment of an orbital floor blowout fracture via the transantral approach involves several critical procedural steps:
After the completion of the procedure, patients are typically monitored for any signs of complications, such as bleeding or infection. Post-operative care may include pain management and instructions for activity restrictions to promote healing. Patients are advised to follow up with their healthcare provider to assess recovery and ensure that any visual disturbances or other symptoms are adequately addressed. The expected recovery period may vary depending on the extent of the injury and the individual patient's healing process.
| Short Descr | OPN TX ORBIT FX TRANSANTRAL | Medium Descr | OPEN TX ORBITAL FLOOR BLOWOUT FX TRANSANTRAL | Long Descr | Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 144 - Treatment, facial fracture or dislocation |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2013-01-01 | Changed | Short Descriptor changed. |
| Pre-1990 | Added | Code added. |
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