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

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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 hyperplasia-524.02) 759.82 Marfan syndrome (see mandibular hyperplasia-524.02) 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, mandibular hypoplasia-524.04, and also 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 Coding Paper 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). PAGE 4 Coding for Orthognathic Surgery
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 Coding Paper 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. PAGE 5 Coding for Orthognathic Surgery
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