Oral Surgery Coding & Reimbursement Alert

Question: Our oral surgeon recently provided treatment for a patient with mandibular fracture. The fracture was sustained in an automobile accident when the patient was in another state. He visited a nearby facility where the surgeon performed open treatment of the fracture. Since he had only gone there for work, he returned to our state and visited our surgeon for post-procedural care. What code should I report for this care that our surgeon provided?

San Francisco Subscriber

Answer: Since the patient underwent an open reduction of a mandibular fracture, you have to select a code from three choices to report the procedure:

• 21454 (Open treatment of mandibular fracture with external fixation)
• 21461 (Open treatment of mandibular fracture; without interdental fixation)
• 21462 (…with interdental fixation)

So, depending on the type of fixation that was done to stabilize the fracture, you will have to use one of these three code choices. But, as your surgeon only provided postoperative management for the patient and did not perform the actual procedure, you will have to report your code choice with the modifier 55 (Postoperative management only) appended to it.

For instance, if only open reduction without any interdental fixation was performed, you report 21461 with the modifier 55. Your use of the modifier will indicate to the payer that your surgeon only performed the postoperative management work for the patient and you will be appropriately reimbursed.

Additional tip: If instead of performing only the postoperative management of the patient, your surgeon was only involved in the preoperative evaluation of the patient, you will have to report the CPT® code with the modifier 56 (Preoperative management only). If your clinician was involved in only the surgical aspect of the treatment as was the case of the surgeon of the other state, you will be reporting the CPT® code with the modifier 54 (Surgical care only) appended.