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The procedure described by CPT® Code 21386 refers to the open treatment of an orbital floor blowout fracture using a periorbital approach. This surgical intervention is specifically designed to address an orbital floor fracture, which is a type of injury that can occur as a result of mid-facial trauma. Such fractures can lead to significant anatomical and functional defects of the eye, including the potential for extraocular muscle entrapment, which may impair eye movement. Additionally, these injuries can result in aesthetic deformities of the face. The periorbital approach involves making an incision along the lower eyelid, allowing the surgeon to access the orbital floor directly. This method is crucial for effectively repairing the fracture and restoring both the structural integrity and function of the affected area. The procedure entails careful dissection and manipulation of the surrounding tissues to ensure that any herniated orbital contents are properly managed, ultimately leading to improved outcomes for the patient.
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The open treatment of an orbital floor blowout fracture using a periorbital approach is indicated for patients who present with specific symptoms and conditions associated with this type of injury. These indications include:
The procedure for the open treatment of an orbital floor blowout fracture involves several critical steps, each designed to ensure effective repair and restoration of function. The steps include:
Post-procedure care following the open treatment of an orbital floor blowout fracture is essential for optimal recovery. Patients are typically monitored for any signs of complications, such as infection or bleeding. Pain management is provided as needed, and patients may be advised to avoid activities that could strain the surgical site. Follow-up appointments are crucial to assess healing and ensure that any visual or functional impairments are addressed promptly. Instructions regarding eye care and activity restrictions will be provided to support the recovery process.
| Short Descr | OPN TX ORBIT FX PERIORBITAL | Medium Descr | OPEN TX ORBITAL FLOOR BLOWOUT FX PERIORBITAL | Long Descr | Open treatment of orbital floor blowout fracture; periorbital approach | 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) | 0 - Co-surgeons not permitted for this procedure. | 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). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | GJ | "opt out" physician or practitioner emergency or urgent service | 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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