Coding for Orthognathic Surgery - American Association of Oral and ...

saving faces|changing lives ® 

Coding for Orthognathic Surgery 

I. INTRODUCTION 

Familiarity and compliance with the previous papers, 

particularly “Procedural Coding Guidelines”, is necessary 

to utilize these codes successfully. 

This report is divided into three parts, patterned upon the 

chronological handling of the orthognathic patient. 

II. Evaluation and Management (E/M) codes (from CPT) 

III. Diagnostic codes (ICD-9-CM Volumes 1 and 2) 

IV. Procedure codes (CPT & CDT) 

II. EVALUATION AND MANAGEMENT (E/M) 

CODES (CPT) 

A. In general, E/M codes would be utilized for office 

based services leading up to the date immediately prior 

to or date of surgery. Codes for E/M are contained 

within the 99200 section of the CPT. To determine the 

appropriate level of E/M service, the guidelines listed 

in CPT and the AAOMS “Procedural Coding Guidelines” 

paper should be followed. The levels and types 

of E/M services vary from OMS to OMS, patient to 

patient, and visit to visit as treatment progresses in the 

orthognathic patient. 

B. Several codes may be useful in reporting additional 

services provided in orthognathic work-ups, and postoperative 

care. 

1. Cephalogram, orthodontic 

(cephalometric radiograph) 70350 

2. Orthopantogram (eg, panoramic x-ray) 70355 

3. Radiologic examination, mandible; 

partial, less than four views 70100 

4. Radiologic examination, mandible; 

complete, minimum of four views 70110 

5. Radiologic examination, facial bones; 

less than three views 70140 

6. Radiologic examination, facial bones; 

complete, minimum of three views 70150 

7. Fabrication of oral surgery splint(s) 

(10 day global period) 21085 

8. Oral/Facial Images (photographs) D0350 

9. Diagnostic casts (study models) D0470 

C. Radiographic 3D assessment of patients continues to 

increase for orthognathic or other craniofacial planning. 

When the OMS provider is reviewing films made 

and interpreted elsewhere, he/she may bill for interpretation 

of the studies when the diagnosis of the OMS 

is different or more extensive than that of the initial 

interpreting physician and documented as such. Since 

the OMS is only providing a professional component, 

not the technical service, the appropriate code requires 

a -26 modifier: 

1. Computed tomography, maxillofacial 

area; without contrast 70486 

2. Computed tomography, maxillofacial 

area; with contrast 70487 

3. 3D rendering with interpretation and 

reporting of computed tomography, 

magnetic resonance imaging, ultrasound, 

or other tomographic modality; not 

requiring image postprocessing on an 

independent workstation 76376 

4. 3D rendering with interpretation and 

reporting of computed tomography, 

magnetic resonance imaging, ultrasound, 

or other tomographic modality; requiring 

image postprocessing on an independent 

workstation 76377 

The last code might be appropriate when manipulating 

3D images for virtual orthognathic surgery. If the manipulation 

is done by the OMS, the code would be used 

without a modifier. 

PAGE 1 Coding for Orthognathic Surgery

D. There are CDT codes for Cone Beam imaging [also 

called 3-D Imaging] which may be applicable in the 

radiographic assessment of some patients: 

Coding Paper 

Cone beam – three-dimensional image 

reconstruction using existing data, 

includes multiple images 

Image with Interpretation 

Cone beam CT capture and interpretation 

with limited field of view - less than one 

whole jaw 


with field of view of one full dental 

arch-mandible 


with field of view of one full dental 

arch-maxilla, with or without cranium 


with field of view of both jaws with or 

without cranium 


for TMJ series including two or more 

exposures 

Image Capture Only 

Cone beam CT image capture with 

limited field of view- less than one 

whole jaw 


field of view of one full dental 

arch- mandible 


field of view of one full dental 

arch-maxilla, with or without 

cranium 


field of view of both jaws, with or 

without cranium 

Cone beam CT image capture for 

TMJ series including two or 

more exposures 

PAGE 2 Coding for Orthognathic Surgery 

D0363 

D0364 

D0365 

D0366 

D0367 

D0368 

D0380 

D0381 

D0382 

D0383 

D0384 

E. There is a family of new codes that represent 

procedures sometimes employed when managing 

patients with skeletal malocclusions, or other 

dentoalveolar disorders. All three codes provide 

skeletal anchorage and include device removal: 

1. Surgical Placement – temporary 

anchorage device [screw retained 

plate] requiring surgical flap 


anchorage device requiring 

surgical flap 


anchorage device without 

surgical flap 

D7292 

D7293 

D7294 

F. There is a code for intraoral fixation device that applies 

to “the placement of an intermaxillary fixation appliance 

used for documented medically accepted treatments 

not in association with fractures.” 

Intraoral placement of a fixation device 

not in conjunction with a fracture 

This CDT code is similar to CPT code 21110 

D7998 

III. DIAGNOSIS CODES (ICD-9-CM MANUAL 

VOLUMES 1 AND 2) 

Note: ICD-9-CM diagnostic coding conventions require 

the surgeon to report diagnosis codes to the highest level 

of specificity (use of a five-digit code rather than a fourdigit 

code). 

A. ICD-9-CM code ranges for orthognathic surgery: 

1. Major anomalies of jaw size (524.00 -524.09). 

Codes 754.0 and 526.89, discussed in paragraph B 

below, are specifically excluded from this section. 

2. Anomalies of relationship of jaw to cranial base 

(524.10 – 524.19) 

3. Anomalies of dental arch relationship 

(524.20 – 524.29) 

4. Malocclusion, unspecified 524.4 (no 5th digit) 

5. Dentoalveolar anomalies (524.70 – 524.79) 

6. Other acquired deformity of the head 

(738.10 – 738.19)

B. ICD-9-CM codes for Syndromes and Conditions Requiring 

Orthognathic Surgery 

Some orthognathic cases may result from syndromes 

and conditions requiring the surgeon to use the following 

codes as primary diagnoses in tandem with the 

developmental codes listed above (see Section IIIA). 

In such cases, the developmental codes will represent 

secondary diagnoses. 

These syndromes are listed below, followed by a parenthetical 

code and descriptor. 

237.7 Neurofibromatosis/von 

Recklinghausen’s disease 

(see mandibular asymmetry: 

Hyperplasia-524.02, or 

Hypoplasia-524.04) (5th digit required) 

253.0 Acromegaly (see mandibular 

hyperplasia-524.02) 

282.4 Thalassemia (see unspecified acquired 

deformity of head 738.10) 

(5th digit required) 

346.8 Mobius syndrome (see mandibular 

hypoplasia-524.04) 

520.5 Amelogenesis imperfecta (see alveolar 

maxillary hyperplasia-524.71, and also 

mandibular hyperplasia-524.02 usually, 

both of these codes will be required for 

secondary diagnosis of amelogenesis 

imperfecta) 

526.89 Unilateral condylar hyperplasia or 

hypoplasia of mandible (since this is the 

only code for the condyle, there is no 

secondary code) 

733.3 Hyperostosis of Skull (includes Stewart- 

Morel syndrome and Leontiasis ossium) 

733.81 Malunion of fracture (see the 

appropriate developmental diagnosis) 

(also use late effect code 905.0) 

733.82 Nonunion of fracture (see the 

appropriate developmental diagnosis) 

(also use late effect code 905.0) 

754.0 Hemifacial atrophy or hemifacial 

hypertrophy (see the appropriate 

developmental diagnosis or see 

unilateral condyle hyperplasia or 

hypoplasia or mandible) 


755.55 Apert’s syndrome/ 

Acrocephalosyndactyly (see maxillary 


Pfeiffer syndrome (see maxillary 

hypoplasia-524.03, and unspecified 

acquired deformity of head-738.10) 

755.59 Cleidocranial Dysplasia/ 

Cleidocranial Dysotosis (see maxillary 

hypoplasia-524.03, and also alveolar 

maxillary hyperplasia-524.71) 

756.0 The following syndromes fall under ICD 

9 CM 756.0 [no 5th digit]: 

Crouzon’s disease (Craniofacial 

dysostosis) (see maxillary 

hypoplasia-524.03, and also unspecified 

acquired deformity of head-738.10) 

Goldenhar syndrome/Hemifacial 

Microsomia (see mandibular 

hypoplasia-524.04, and also 

microgenia-524.06) 

Hallermann-Streiff syndrome (see 

mandibular hypoplasia-524.04, and also 


Robin Complex/Pierre-Robin 

syndrome/ Robin Anomalad (see 



Treacher-Collins syndrome/ 

Mandibulofacial Dysostosis (see 

zygomatic hypoplasia-738.12, 

Mandibular Hypoplasia-524.04, and also 

unilateral condyle hypoplasia-526.89. 

Note: Use all secondary codes) 

756.4 Achondroplasia (see maxillary 


756.51 Osteogenesis Imperfecta (see 

mandibular hyperplasia-524.02) 


756.52 Osteopetrosis/Albers-Schonberg’s 

disease (see maxillary hypoplasia, 

524.03, and also mandibular hypoplasia, 

524.04) 

756.55 Chondroectodermal Dysplasia/Ellis- 

Van Creveld syndrome (see mandibular 

hypoplasia-524.04, and also unilateral 

condyle hypoplasia, 526.89) 

756.83 Ehlers-Danlos syndrome (see alveolar 

maxillary hyperplasia-524.71) 

758.7 Klinefelter syndrome (see mandibular 


759.82 Marfan syndrome (see mandibular 


759.89 Gorlin syndrome/Basal Cell Nevus 

syndrome (see unspecified acquired 

deformity of head-738.10, and also 

mandibular hyperplasia-524.02) 

780.53 Hypersomnia with sleep apnea 

(see maxillary hypoplasia-524.03, 


microgenia-524.08, Note: Use all three 

secondary codes, if appropriate) 

IV. PROCEDURE CODES (CPT) 

CPT codes are used to report orthognathic surgery procedures 

using the CMS-1500 claim form. Since orthognathic 

procedures are most likely covered by medical carriers, 

discussion here will be limited to CPT codes. Note, 

however, with the implementation of “recognized code 

sets” under HIPAA, “D-codes” may be used for reporting 

purposes if an appropriate CPT code is not available. For 

example, D7944 Osteotomy – segmented or subapical, 

Report by range of tooth numbers within the segment” 

may actually be an exception to the rule that orthognathic 

procedures are more specific in CPT as opposed to CDT. 

Technically, the CPT 21198, although it says “segmental,” 

is not clearly subapical; 21199 includes genial tubercle 

(which is in basilar bone), and 21206 cites examples 

that are not clearly segmental and do not really have the 

specificity that D7944 has. The existence of a code (CPT 

or CDT) does not guarantee reimbursement for the service. 

A. General Guidelines 


1. Global surgical package: A given surgical procedure 

code usually comprises services provided within 

24 hours prior to surgery, the surgical procedure, 

postoperative care in the hospital, and routine postoperative 

care in the office. This period is usually 

90 days, since orthognathic surgery is considered a 

major surgical procedure. 

2. Hospital discharge services (99238) are considered 

part of the surgical package and would not be used 

by the surgeon for services done on the final day of 

hospitalization. In general, the surgeon should not 

bill any E/M service codes during the patient’s stay 

related to an orthognathic procedure. However, a 

Significant, Separately Identifiable E&M Service by 

the Same Physician on the Same Day of the Procedure 

can be submitted using the appropriate E/M 

code and -25 modifier and appropriate documentation. 

3. Postoperative visit (99024) is used to report routine 

postoperative visits during the global period for the 

surgery, usually 90 days for orthognathic surgery. 

This code is for reporting purposes only, as reimbursement 

for routine postoperative care is typically 

included in the surgical code itself. 

4. Postoperative x-rays, even when done within the 

global period, may be billed (they are not considered 

to be a routine E&M service). Postoperative services 

which significantly exceed normal postoperative 

care may be submitted with an appropriate E/M 

code and the –25 modifier. Modifier -25 is defined 

as a Significant, Separately Identifiable E&M Service 

by the Same Physician on the Same Day of the 

Procedure or Other Service. A letter of explanation 

and clear documentation to substantiate the claim 

will usually be required 

5. Postoperative services delivered within the global 

period, but which are unrelated to the original procedure, 

may be billed using modifier -24. 

6. An unplanned but related return to the operating or 

procedure room during the postoperative period is 

reported with a -78 modifier. 

7. These codes are considered to be inherently bilateral. 

Do not add the bilateral modifier. 

8. When reporting a unilateral mandible ramus procedure, 

use the “-52” modifier (Reduced Services). 


B. Reporting Orthognathic Surgery Procedures: 

1. In general, use codes in the range 21120- 21209. 

Code “21210, Graft, bone; nasal, maxillary, or malar 

areas (includes obtaining graft),” should not be 

combined with LeFort codes 21145-21147, or higher 

level LeFort codes 21151 through 21160, unless the 

21210 related graft is totally separate from the Le- 

Fort procedure. Modifiers -51 and -52 would apply. 

2. Use the “-51” modifier on multiple procedures and 

follow CPT Guidelines. 

3. Osteotomy codes “requiring a bone graft”, but 

which specify “includes obtaining autograft,” or 

“includes obtaining graft,” should be appended 

with a -52 modifier if an allograft is utilized. The 

same principle would apply to the 21210 and 21215 

codes. 

4. Use the same descriptor for better communication 

and to avoid confusion. 

21196 is the same as “SSO with bone plates,” “Obwegeser 

osteotomy with RIF,” and “Sliding osteotomy 

with rigid fixation.” 

5. If a second surgeon, assistant surgeon, co-surgeon 

operates, the appropriate modifier should be used 

(see modifiers -62, -66, -80, -81, -82 listed in Appendix 

A of your CPT manual). 

6. Application of interdental fixation device for conditions 

other than fracture or dislocation includes 

removal (21110) 

C. A Word about Distraction Osteogenesis (DO) 

DO is essentially an osteotomy, not taken to 

completion, with application of an appliance and 

subsequent adjustments to move the osteotomy 

segments. It is coded using the appropriate osteotomy 

code with a -52 modifier, as well as 20690 (Application 

of a uniplane [pins or wires in one plane], unilateral, 

external fixation system) or 20692 (Application of 

a multiplane [pins or wires in more than one plane], 

unilateral, external fixation system [eg, Ilizarov, 

Monticelli type]. Both 20690 and 20692 are unilateral 

codes, and the -50 modifier would be used for a 


bilateral procedure. 20693 is used if adjustment of 

an external distractor device requires IV sedation or 

general anesthesia. If an external distractor is adjusted 

without anesthesia or with only local anesthesia within 

the global period, the service is not billed. The same 

principles apply for the use of CPT 20694, removal, 

under anesthesia, of external fixation system. 

D. Adjunctive Procedures 

1. Generally excluded as “Cosmetic” 

a. Lipectomy (15838) 

b. Facial implants for augmentation 

(21125) 

c. Bony augmentation and osteoplasty 

(21127, 21208 – 21209) 

d. Genioplasty for cosmetic reasons 

(21120-21123) 

(Reporting does not assure 

reimbursement if the procedure is 

contractually excluded by the carrier) 

2. Genioplasty for sleep apnea (hypersomnia with 

sleep apnea-780.53) should be submitted with documentation 

of the diagnosis, such as sleep studies, 

notes, etc. 

3. Platelet Rich Plasma (PRP) is sometimes used 

as an adjunct to certain orthognathic procedures. 

When appropriate, it is reported with 0232T- injection(s), 

platelet rich plasma, any tissue, including 

image guidance, harvesting and preparation when 

performed. Code 0232T is a category III CPT code 

which is a temporary code describing an emerging 

technology, service and /or procedure that may or 

may not eventually be converted to a Category I 

CPT code. 


V. SUMMARY 

This paper is intended to be a general guideline for orthognathic 

surgery diagnostic and procedural coding. In order 

to stay current with the evaluation and management (CPT) 

codes, the diagnosis (ICD-9-CM) codes, and the procedure 

(CPT & CDT) codes, members should use the most current 

coding manuals. AAOMS publications such as AAOMS 

Today will provide updates and advisory opinions. Members 

are also encouraged to participate in AAOMS Coding 

courses for additional training. Contact the AAOMS for 

the current Coding and Billing courses brochure. 

Note: This paper should not be used as the sole reference in coding. 

Both diagnosis and treatment codes change frequently, and insurance 

carriers may differ in their interpretations of the codes. 

Coding and billing decisions are personal choices to be made by 

individual oral and maxillofacial surgeons exercising their own professional 

judgment in each situation. The information provided to you in 

this paper is intended for educational purposes only. In no event shall 

AAOMS be liable for any decision made or action taken or not taken 

by you or anyone else in reliance on the information contained in this 

article. For practice, financial, accounting, legal or other professional 

advice, you need to consult your own professional advisers. 


This is one in a series of AAOMS papers designed to provide 

information on coding claims for oral and maxillofacial surgery 

(OMS). This paper discusses coding for orthognathic surgery. 

This paper is to aid the oral and maxillofacial surgeon with 

proper diagnosis (ICD-9-CM) and treatment (CPT/CDT) coding 

for orthognathic surgery. When indicated, you will be referred to 

the appropriate area of the coding books where the principles of 

coding illustrated in this paper may be applied. 

Proper coding provides a uniform language to describe medical, 

surgical, and dental services. Diagnostic and procedure codes 

are continually updated or revised. The AAOMS Committee on 

Health Care and Advocacy has developed these coding guidelines 

in order to assist the membership to use the coding systems 

effectively and efficiently. 

© 2013 American Association of Oral and Maxillofacial Surgeons. 

No portion of this publication may be used or reproduced without 

the express written consent of the American Association of Oral 

and Maxillofacial Surgeons. 

Revised March 2013

Coding for Orthognathic Surgery - American Association of Oral and ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?