Neurosurgery Coding Alert

Question: The surgeon performed treatment on a LeFort III craniofacial separation.  Which codes — CPT^® and ICD-10 — are most appropriate for this surgery?

Alaska Subscriber

Answer: The CPT^® code will depend on a couple of factors. Follow this advice for the correct coding choice:

• Report 21432 (Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation) for “non-complicated” craniofacial separation surgery. You’ll use this code when the encounter notes indicate that the surgeon used internal fixation/wiring during a 21432 procedure.
• Report 21433 (… complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches) for the first type of complicated craniofacial separation surgery. You’ll use this code when encounter notes indicate that the injury was comminuted or involved cranial nerve foramina—and that the surgeon employed multiple approaches to complete the procedure (i.e. both extracranial and intracranial approaches).
• Report 21435 (… complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation)) for the second type of complicated craniofacial separation surgery. You’ll use this code when encounter notes indicate that the injury was complicated and involved external fixation or a combination of internal and external fixation techniques.

For the ICD-10 code, append S02.413- (LeFort III fracture) to whichever surgical code you settle on. Remember to finish the code with the appropriate 7th character from the list below:

• A = initial encounter for closed fracture
• B = initial encounter for open fracture
• D = subsequent encounter for fracture with routine healing
• G = subsequent encounter for fracture with delayed healing
• K = subsequent encounter for fracture with nonunion
• S = sequela

Return trip reminder: If a patient returns to the surgeon for removal of any devices used for fixation during this surgery, report 20670 (Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure)) with S02.413- appended.