21141

🦷 CPT Code 21141 — Reconstruction of Midface, Le Fort I; Single Piece, Movement in Any Direction

Quick Reference

Global Period: 090 days | wRVU: 20.69 | Assistant Payable: ✅ Yes | Co-Surgeon: ✅ Yes | Category: Musculoskeletal – Head | Procedure: Le Fort I Maxillary Osteotomy, Single Piece | Bone Graft: ❌ Not Included

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📋 Official CPT Description

CPT 21141 — Reconstruction of midface, Le Fort I; single piece, movement in any direction

This code describes the Le Fort I level maxillary osteotomy performed as a single-piece mobilization of the tooth-bearing maxillary segment, which is repositioned in any direction — anteriorly (advancement), posteriorly (setback), superiorly (impaction), inferiorly (downgrafting), or any combination of spatial movements — without the use of a bone graft. 21141 is the foundational Le Fort I code, representing the single-piece maxillary osteotomy performed without bone graft — the most commonly performed maxillary orthognathic procedure in contemporary oral and maxillofacial surgery practice.

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🧠 Detailed Clinical Description

Historical Context — The Le Fort Osteotomy

The Le Fort osteotomy is named after French surgeon René Le Fort, who in 1901 described three consistent patterns of midfacial fractures occurring from blunt trauma to the face. These fracture patterns — Le Fort I, II, and III — defined anatomical planes of relative structural weakness in the midface skeleton. Orthognathic surgeons subsequently adapted these fracture lines as intentional surgical osteotomy planes, enabling controlled repositioning of midfacial segments for deformity correction.

• Le Fort I — Transverse osteotomy through the lower maxilla, separating the tooth-bearing maxillary alveolus from the upper midface
• Le Fort II — Pyramidal osteotomy separating the central midface including the nose from the upper face
• Le Fort III — Complete craniofacial dysjunction separating the entire midface from the skull base

Note

21141 specifically captures the Le Fort I level, the lowest and most commonly employed surgical plane in orthognathic surgery.

Anatomical Basis of the Le Fort I Osteotomy

The Le Fort I osteotomy transects the following anatomical structures bilaterally:

Structure Cut	Anatomical Description
Anterior maxillary wall	Horizontal cut through the piriform aperture rim bilaterally, above the root apices
Lateral maxillary wall	Continuation of anterior cut posterolaterally across the zygomaticomaxillary buttress
Pterygomaxillary junction	Posterior separation at the pterygomaxillary fissure using a curved osteotome; divides pterygoid plates from maxillary tuberosity
Nasal septum	Septal osteotome used to separate the nasal septum from the maxillary crest, allowing downfracture
Lateral nasal walls	Curved sinus osteotomes separate the lateral nasal wall from the septum superiorly within the nasal cavity

Note

After all four cuts are completed bilaterally and the nasal septum is freed, the maxilla is downfractured — mobilized inferiorly using firm digital pressure and Rowe disimpaction forceps — freeing the tooth-bearing segment as a single mobile unit.

The “Single Piece” Designation

The single piece qualifier in 21141 means the entire tooth-bearing maxilla is mobilized and repositioned as one unified segment — the standard Le Fort I. This contrasts with:

• 21142 — Le Fort I, two pieces: maxilla is additionally segmented with a midline or parasagittal osteotomy (e.g., surgically assisted rapid palatal expansion [SARPE] element, or two-piece maxilla for arch width discrepancy)
• 21143 — Le Fort I, three or more pieces: multiple interdental osteotomies divide the maxilla into three or more segments for complex multiplanar arch form correction

Movement Directions Captured Under 21141

21141 covers any direction of movement — a single code applies regardless of the vector or combination of vectors:

Direction	Clinical Application	Example Measurement
Advancement (anterior)	Maxillary hypoplasia; Class III skeletal; post-cleft hypoplasia	3–8 mm forward movement
Impaction (superior)	Vertical maxillary excess (gummy smile); correction of open bite	3–6 mm superior movement
Downgraft (inferior)	Vertical maxillary deficiency; short lower face height	2–4 mm inferior movement (requires bone graft → use 21145)
Setback (posterior)	Maxillary hyperplasia (rare in isolation)	2–4 mm posterior movement
Rotation (yaw/pitch/roll)	Canting correction; asymmetric repositioning	Combined rotational vectors
Combination movements	Most common — impaction + advancement; advancement + lateral repositioning	Multi-vector repositioning

Downgraft and Bone Graft → 21145, Not 21141

When the maxilla is moved inferiorly (down-grafted) creating a gap at the osteotomy site, autologous or allograft bone is typically required to fill the space and prevent relapse. In this scenario, the correct code is 21145 (Le Fort I, single piece, with bone graft) — not 21141. The presence or absence of bone graft is the defining distinction between 21141 and 21145. Similarly, 21142 → 21146 (two-piece with graft), and 21143 → 21147 (three or more pieces with graft).

Clinical Indications for 21141

Indication	Description	Direction of Movement
Maxillary hypoplasia	Underdeveloped upper jaw; Class III skeletal; midfacial retrusion	Advancement
Vertical maxillary excess	”Gummy smile”; excessive incisor show; skeletal open bite	Impaction
Maxillary retrognathia	Recessed upper jaw relative to mandible; Angle’s class III	Advancement ± impaction
Post-cleft palate maxillary hypoplasia	Secondary to scarring from palate repair; class III malocclusion	Advancement (often LeForte I + BSSO)
Skeletal anterior open bite	Posterior dentoalveolar excess; mandibular plane rotation	Impaction + autorotation
Obstructive sleep apnea (MMA)	Maxillary advancement as part of maxillomandibular advancement	Significant advancement (8–12 mm)
Dentofacial asymmetry	Canting of maxillary occlusal plane; unilateral hypoplasia	Differential impaction or advancement
Craniofacial syndromes	Apert, Crouzon, Pfeiffer syndromes — midface hypoplasia	Advancement ± distraction
Post-traumatic maxillary deformity	Malunited LeFort fractures	Variable — corrective repositioning

Surgical Steps Included in 21141

1. Preoperative planning — Cephalometric analysis, digital dental models, 3D virtual surgical planning (VSP), fabrication of surgical occlusal splint/wafer; not separately billable within global
2. Patient positioning and airway — Nasotracheal intubation (standard); throat pack placement
3. Vasoconstrictor injection — Local anesthetic with epinephrine injected into maxillary vestibule bilaterally for hemostasis
4. Vestibular incision — Horizontal incision through mucosa from first molar to first molar region across the maxillary vestibule, staying above the attached gingiva
5. Subperiosteal dissection — Elevation of mucoperiosteal flap exposing the anterior maxillary wall, piriform apertures, zygomaticomaxillary buttresses, and pterygomaxillary junction bilaterally
6. Anterior horizontal osteotomy — Reciprocating saw cut across the anterior maxillary wall bilaterally, typically 5 mm above the root apices; cut passes through the piriform rim
7. Lateral wall osteotomy — Continuation of horizontal cut posterolaterally across the zygomaticomaxillary buttress; curved bur or saw
8. Nasal septum osteotomy — Curved septal osteotome introduced through anterior nasal spine, separating the nasal septum/vomer from the maxillary crest; protects nasal septum blood supply
9. Lateral nasal wall osteotomy — Curved osteotomes separate lateral nasal walls within the nasal cavity from the septum and turbinate attachments
10. Pterygomaxillary dysjunction — Curved (Tessier) osteotome placed at pterygomaxillary fissure bilaterally; controlled mallet strike separates pterygoid plates from maxillary tuberosity — the most technically sensitive step (bleeding risk from descending palatine artery)
11. Downfracture — Firm bilateral inferior pressure on the maxilla (digital or Rowe forceps) mobilizes segment; confirmed by free mobility in all planes
12. Mobilization and repositioning — Disimpaction forceps used to complete mobilization; maxilla repositioned to planned position using intermediate or final surgical splint
13. Occlusal verification — Splint seated; maxillary arch ligated to mandibular arch (light IMF) to confirm planned occlusion and skeletal position
14. Internal fixation — Titanium miniplates (typically L-shaped or straight; 1.5 mm or 2.0 mm) applied at bilateral piriform aperture rims and zygomaticomaxillary buttresses (4 plates standard); screws placed
15. IMF release — Ligatures released; occlusion and condylar seating verified
16. Hemostasis — Hemostatic agents at pterygomaxillary junction bilaterally; gelfoam or similar at nasal cavity
17. Wound closure — Mucosal closure of vestibular incision with resorbable sutures; V-Y closure at anterior nasal spine region to prevent alar base widening (alar cinch suture)
18. Alar cinch suture — Circumnarial sutures placed to prevent undesired alar base widening — a standard maneuver integrated into wound closure

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💰 Reimbursement & RVU Profile

Component	Value
Work RVU (wRVU)	20.69 CMS MPFS 2025
Global Period	090 days
Assistant Surgeon Payable	✅ Yes
Co-Surgeon Payable	✅ Yes
Team Surgery	❌ No
Facility Only	Yes (hospital/ASC setting)
Multiple Procedure Indicator	2 (standard reduction applies)
Bilateral Surgery Indicator	0

wRVU Comparison — Le Fort I Family and Related Codes

Code	wRVU	Procedure
21141	20.69	Le Fort I, single piece, no graft (this code)
21142	~23.18	Le Fort I, two-piece, no graft
21143	~25.91	Le Fort I, three or more pieces, no graft
21145	~24.17	Le Fort I, single piece, WITH bone graft
21146	~26.42	Le Fort I, two-piece, WITH bone graft
21147	~29.01	Le Fort I, three or more pieces, WITH bone graft
21196	~21.81	BSSO with rigid fixation (mandibular component)

21141 + 21196 combined (bimaxillary orthognathic surgery) represents the most commonly billed orthognathic procedure pair, with a combined wRVU approaching ~42.50 — reflecting one of the highest-complexity elective head and neck procedure combinations in ambulatory surgical practice.

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✅ Included Services (Bundled into 21141)

The following are not separately reportable when performed as integral components of 21141:

• All maxillary osteotomies required to complete the Le Fort I (anterior wall, lateral wall, nasal septum, lateral nasal wall, pterygomaxillary dysjunction)
• Downfracture maneuver and segment mobilization
• Nasal septum osteotomy integrated into the Le Fort I approach
• Intraoperative occlusal splint seating and use for repositioning guidance
• Intraoperative intermaxillary fixation for occlusal verification
• Internal fixation hardware placement (miniplates and screws) at osteotomy sites
• Alar cinch sutures (integrated wound closure maneuver — not a separate rhinoplasty component)
• Mucosal wound closure at vestibular incision (simple/intermediate)
• Drain placement at operative site
• Routine postoperative management within 90-day global period (wound checks, elastic guidance, occlusal monitoring, splint management)
• Routine hardware adjustment within the global period (non-OR based)
• Routine splint removal within global period

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❌ Excludes / Separately Reportable Services

The following may be billed separately when clearly documented as distinct services:

Separate Service	Code
Bilateral sagittal split osteotomy of mandible with rigid fixation	21196
BSSO without rigid fixation (historical)	21195
Genioplasty, sliding osteotomy (single piece)	21121
Genioplasty, sliding osteotomy, two or more pieces	21122
Genioplasty with bone graft augmentation	21123
Genioplasty, augmentation (alloplastic)	21120
Le Fort I, two-piece maxilla (if segmented)	21142
Le Fort I, three or more pieces (if multi-segmented)	21143
Le Fort I, single piece WITH bone graft	21145
Le Fort II osteotomy (if performed at higher level)	21150, 21151
Le Fort III osteotomy	21154, 21155, 21160
Bone graft harvest and placement (when downgraft performed)	20900, 20902
Septoplasty — if performed as a distinct, separately indicated procedure	30520
Inferior turbinate reduction — if separately indicated	30130, 30140
Inferior turbinate outfracture only (as part of nasal airway)	30130
Mandibular rami reconstruction with bone grafts, bilateral	21193
TMJ arthroplasty or reconstruction	21240, 21242, 21244
Alloplastic TMJ replacement	21243
Distraction osteogenesis device placement	21110
Return to OR during global period for related complication	21141 with modifier 78
Hardware removal (separate OR session, separate encounter)	20670, 20680
Presurgical orthodontic management	Orthodontic codes (D8080, D8090 — dental)
Surgical splint/wafer fabrication (laboratory)	21085
Diagnostic imaging/planning (VSP, CBCT)	Radiology codes if separately billable

Septoplasty and 21141 — The Most Contested Bundling Issue

Septoplasty (30520) is one of the most frequently disputed additional codes when billed alongside 21141. The nasal septum osteotomy performed as part of the Le Fort I downfracture is integral to 21141 and not separately billable. However, when a distinct septal deviation is corrected for independent functional airway obstruction — involving submucosal resection, cartilage scoring, or turbinate work beyond what is required for the Le Fort I approach — septoplasty may be separately reportable with modifier -59. The key documentation requirements are:

• Preoperative diagnosis of nasal obstruction or deviated septum as a separate clinical indication (not just part of the orthognathic surgical approach)
• Operative report describing distinct septal work beyond the routine septum osteotomy integral to the Le Fort I
• Separate paragraph in the operative note documenting the septoplasty as a distinct procedure with its own indications

Without this documentation, payers will routinely deny 30520 as bundled with 21141.

Inferior Turbinate Work and 21141

Similarly, inferior turbinate reduction (30130, 30140) is separately reportable only when performed for independently documented nasal airway obstruction beyond what is encountered during routine Le Fort I access. Turbinate outfracture performed solely to gain surgical access for the Le Fort I osteotomy is not separately billable. Document the preoperative turbinate hypertrophy as a distinct diagnosis and describe the turbinate reduction procedure independently in the operative report.

Alar Cinch and V-Y Advancement — Not Separately Billable

The alar cinch suture and anterior nasal spine V-Y mucosal advancement are integral components of the Le Fort I wound closure and are not separately reportable as rhinoplasty or soft tissue suspension procedures. These are standard technique maneuvers included in 21141.

Le Fort I + BSSO — The Most Common Multi-Code Scenario

When 21141 is paired with 21196 (bimaxillary orthognathic surgery), both codes are reportable — each describes a distinct procedure at a distinct anatomical level (maxilla vs. mandibular rami). Append modifier -51 to the lesser-valued procedure. This is well-established in NCCI as separately reportable. Never assume the maxillary Le Fort I is bundled into the BSSO code or vice versa.

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🔬 Le Fort I Code Family — Detailed Comparison

Selecting the Correct Le Fort I Code

Code	Pieces	Bone Graft	wRVU	Key Indicator
21141	1	❌ No	20.69	Standard Le Fort I; impaction, advancement, or setback only
21142	2	❌ No	~23.18	Midline or parasagittal segmentation; two mobile pieces
21143	3+	❌ No	~25.91	Multiple interdental osteotomies; arch width expansion
21145	1	✅ Yes	~24.17	Downgraft with gap requiring bone graft
21146	2	✅ Yes	~26.42	Two-piece Le Fort I with downgraft and graft
21147	3+	✅ Yes	~29.01	Multi-segmented Le Fort I with downgraft and graft

The Bone Graft Decision Point

The critical branch point in Le Fort I code selection is whether a bone graft was required. This is almost always driven by the direction of movement:

• Impaction (superior) — Bone is telescoped; no gap; no graft needed → 21141
• Advancement (anterior only) — No significant gap at buttresses if plated correctly; typically no graft → 21141
• Downgraft (inferior) — Creates a gap at osteotomy site; graft required to prevent relapse → 21145
• Combined advancement + downgraft — Gap at anterior osteotomy sites; graft required → 21145

Read the operative report carefully for documentation of graft harvest and placement before code selection.

Two-Piece vs. Single-Piece Decision (21141 vs. 21142)

A two-piece Le Fort I (21142) involves an additional interdental osteotomy — typically a midline or parasagittal vertical cut through the palate — dividing the single maxillary segment into two independently mobile pieces. This is performed when:

• The maxillary arch requires transverse widening not achievable orthodontically
• There is a midline discrepancy requiring independent repositioning of left and right maxillary halves
• Surgically assisted rapid palatal expansion (SARPE) is the primary goal

Note

If the operative report describes the maxilla moved as a single unit without additional segmental cuts, 21141 is correct. If interdental osteotomies are described creating two distinct mobile pieces, 21142 applies.

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🏷️ Applicable Modifiers

Modifier	Description	When to Use
-51	Multiple procedures	When 21141 is performed alongside 21196 (BSSO), genioplasty, septoplasty, or other major procedures in the same session; append to lesser-valued procedure
-59	Distinct procedural service	Unbundle separately identifiable services at distinct anatomical sites — septoplasty, turbinate reduction when separately indicated and documented
-22	Increased procedural complexity	Prior cleft palate surgery (scarred anatomy), prior Le Fort fracture with malunion, craniofacial syndrome with distorted midface anatomy, morbid obesity limiting access, dramatically prolonged OR time; requires specific operative documentation and cover letter
-52	Reduced services	Planned procedure partially completed (e.g., pterygomaxillary dysjunction could not be safely completed unilaterally due to vascular concern); rare
-58	Staged or related procedure by same surgeon	Planned secondary procedure within global period (e.g., hardware removal, secondary bone grafting, distraction adjustment)
-78	Return to OR for related procedure during global period	Re-exploration for hardware failure, plate fracture, segment relapse requiring surgical correction, hemorrhage from descending palatine artery, within 90-day global
-79	Unrelated procedure during global period	Separate, unrelated surgery within 90 days
-80	Assistant surgeon	Second surgeon assisting; common and medically necessary in bimaxillary surgery — payable for 21141
-82	Assistant surgeon (no qualified resident)	Teaching hospital alternative when no resident available
-AS	Assistant at surgery – NP/PA	Non-physician practitioner assisting at table

Modifier -22 — Strongest Justifications for 21141

The following clinical scenarios most strongly support modifier -22 with 21141:

• Prior cleft palate repair with extensive palatal scarring — scar tissue in the palate and maxillary vestibule distorts tissue planes, increases bleeding risk, and makes mobilization significantly more difficult
• Prior failed Le Fort I — Hardware removal, re-osteotomy through scar and existing hardware, re-mobilization of previously operated maxilla
• Severe post-traumatic maxillary deformity with fibrous or bony malunion requiring osteotome work to re-fracture malunited segments
• Craniofacial syndromes (Apert, Crouzon) — Multiple prior surgeries, distorted anatomy, rigid fibrous midface
• Significant obesity with restricted access to posterior maxilla and pterygomaxillary junction
• Prolonged OR time substantially exceeding typical range for 21141 (~2.5–3.5 hrs for Le Fort I alone; >5 hrs for Le Fort I alone warrants -22 with documentation)

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🩺 ICD-10-CM Diagnoses Commonly Paired with 21141

Maxillary Skeletal Deformities — Primary Indications

ICD-10-CM	Description	HCC?
M26.02	Maxillary hypoplasia	❌
M26.01	Maxillary hyperplasia	❌
M26.00	Unspecified anomaly of jaw size	❌
M26.09	Other specified anomalies of jaw size	❌

M26.02 — The Primary Code for Le Fort I in Maxillary Hypoplasia

M26.02 (Maxillary hypoplasia) is the most commonly assigned principal diagnosis for 21141 when the indication is maxillary retrognathia or retrusion — the most frequent Le Fort I indication. It captures the underdevelopment of the upper jaw requiring advancement and supports medical necessity. Pair with malocclusion codes to fully document the dental-skeletal basis for surgery.

Jaw-Cranial Base Relationship Anomalies

ICD-10-CM	Description	HCC?
M26.10	Unspecified anomaly of jaw-cranial base relationship	❌
M26.11	Maxillary asymmetry	❌
M26.12	Other jaw asymmetry	❌
M26.19	Other specified anomalies of jaw-cranial base relationship	❌

Dental Arch Relationship / Malocclusion

ICD-10-CM	Description	HCC?
M26.211	Malocclusion, Angle’s class I	❌
M26.212	Malocclusion, Angle’s class II	❌
M26.213	Malocclusion, Angle’s class III	❌
M26.20	Unspecified anomaly of dental arch relationship	❌
M26.29	Other anomalies of dental arch relationship	❌
M26.51	Abnormal jaw closure	❌

Malocclusion Coding for Medical Necessity

Payers scrutinize 21141 claims extensively for proof that the malocclusion has an underlying skeletal basis not correctable by orthodontics alone. The combination of:

• M26.02 (skeletal hypoplasia) + M26.213 (Class III malocclusion) — is the archetypal diagnostic pair for Le Fort I advancement in Class III patients and is the strongest medical necessity argument for commercial payer authorization. Never code malocclusion alone without the accompanying skeletal anomaly diagnosis.

Open Bite

ICD-10-CM	Description	HCC?
M26.220	Open occlusal relationship, unspecified	❌
M26.221	Open occlusal relationship, anterior	❌
M26.222	Open occlusal relationship, posterior	❌

Vertical Maxillary Excess

ICD-10-CM	Description	HCC?
M26.01	Maxillary hyperplasia	❌
M26.09	Other specified anomalies of jaw size	❌
M26.37	Other specified anomalies of tooth position of fully erupted tooth or teeth	❌

Vertical Maxillary Excess (VME) and Le Fort I Impaction

Vertical maxillary excess — characterized by excessive incisor display (“gummy smile”), long lower facial height, and skeletal anterior open bite — is one of the most common indications for Le Fort I impaction. The maxilla is moved superiorly, reducing vertical facial height and allowing autorotation of the mandible upward to close the open bite. ICD-10-CM lacks a dedicated VME code; use M26.01 (maxillary hyperplasia) in the vertical dimension context, combined with M26.221 (anterior open bite) when applicable. Document the vertical measurement explicitly in the clinical record.

Craniofacial Syndromes and Congenital Conditions

ICD-10-CM	Description	HCC?
Q75.0	Craniosynostosis	❌
Q75.1	Craniofacial dysostosis (Crouzon syndrome)	❌
Q75.4	Mandibulofacial dysostosis (Treacher Collins)	❌
Q87.0	Congenital malformation syndromes predominantly affecting facial appearance	❌
Q87.1	Congenital malformation syndromes with short stature	❌
Q38.0	Anomalies of lips	❌
Q35.9	Cleft palate, unspecified	❌
Q37.9	Unspecified cleft palate with cleft lip	❌
Q36.9	Cleft lip, unspecified	❌
Q67.4	Other congenital deformities of skull, face and jaw	❌

Post-Cleft Le Fort I — A High-Complexity Scenario

Post-cleft palate maxillary hypoplasia is among the most challenging Le Fort I indications:

• Palatal scarring from prior repair restricts mobilization and increases hemorrhage risk
• Bone grafts are frequently required (shifting to 21145) due to cleft-related alveolar defects
• Fistula risk is elevated in patients with residual palatal defects
• Prior bone grafting to the alveolus (secondary alveolar bone graft) may alter anatomy

Always review the prior operative and orthodontic records before coding a cleft-related Le Fort I — and evaluate whether modifier -22 and/or the bone graft code (21145) better capture the complexity.

Obstructive Sleep Apnea — MMA Context

ICD-10-CM	Description	HCC?
G47.33	Obstructive sleep apnea (adult)	❌
G47.30	Sleep apnea, unspecified	❌
R06.83	Snoring	❌
R06.5	Mouth breathing	❌
M26.04	Mandibular hypoplasia (co-existing retrognathia — MMA context)	❌
M26.02	Maxillary hypoplasia (co-existing retrognathia — MMA context)	❌

OSA-Driven MMA — Insurance Documentation Burden

When 21141 is performed as part of maxillomandibular advancement (MMA) for obstructive sleep apnea, payers (including Medicare) require:

1. ✅ Diagnostic polysomnography (PSG) confirming OSA — AHI ≥15 or AHI ≥5 with symptoms
2. ✅ CPAP trial documentation — typically ≥3 months with demonstrated intolerance or inadequate response
3. ✅ Cephalometric analysis demonstrating skeletal component of airway obstruction (reduced posterior airway space, retrognathia)
4. ✅ Sleep medicine/pulmonology consultation
5. ✅ Surgeon medical necessity letter with anatomic basis for surgical intervention
6. ✅ BMI within acceptable range (morbid obesity as sole driver typically not covered)

Missing CPAP failure documentation is the most common cause of MMA claim denial. Confirm this documentation is in the pre-authorization packet before scheduling.

Temporomandibular Joint Disorders (When Contributing)

ICD-10-CM	Description	HCC?
M26.601	Right TMJ disorder, unspecified	❌
M26.602	Left TMJ disorder, unspecified	❌
M26.603	Bilateral TMJ disorder, unspecified	❌
M26.621	Arthralgia of right temporomandibular joint	❌
M26.631	Articular disc disorder of right temporomandibular joint	❌
M26.641	Ringing in right ear	❌

Post-Traumatic Maxillary Deformity

ICD-10-CM	Description	HCC?
M84.38XA	Stress fracture, other site, initial encounter	❌
S02.400A	Malar fracture, unspecified, initial encounter	❌
S02.411A	Le Fort I fracture, initial encounter for closed fracture	❌
S02.412A	Le Fort I fracture, initial encounter for open fracture	❌
M84.68XA	Pathological fracture in other disease, other site, initial	❌
S02.40XA	Fracture of malar and maxillary bones, unspecified, initial	❌
T79.3XXA	Post-traumatic wound infection, initial encounter	❌
M26.39	Other anomalies of tooth position — post-traumatic	❌

Le Fort I for Malunited Fractures

When 21141 is performed for correction of a malunited Le Fort I fracture — a post-traumatic deformity — the principal diagnosis should reflect the malunited fracture or post-traumatic deformity:

• Active/acute phase: S02.411A or S02.40XA with appropriate injury code context
• Malunion (healed but deformed): Code the resulting deformity (M26.02, M26.12) and document the traumatic etiology in the medical record
• Modifier -22 is almost universally appropriate in post-traumatic Le Fort I — fibrous or bony malunion significantly increases operative complexity

Complicating Conditions — CC/MCC Capture

ICD-10-CM	Description	HCC?
E11.9	Type 2 diabetes mellitus without complications	✅ HCC 19
E66.01	Morbid (severe) obesity due to excess calories	❌
E43	Unspecified severe protein-calorie malnutrition	✅ HCC 21
E44.0	Moderate protein-calorie malnutrition	✅ HCC 21
D62	Acute posthemorrhagic anemia	❌
J96.00	Acute respiratory failure, unspecified	✅ HCC 84
I10	Essential (primary) hypertension	❌
G47.33	Obstructive sleep apnea (adult)	❌
Z87.39	Personal history of other musculoskeletal disorders	❌
Z98.890	Other specified postprocedural states (prior maxillary surgery)	❌

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🏨 MS-DRG Mapping

Inpatient Context

In the inpatient acute care hospital setting, procedures are coded using ICD-10-PCS — CPT codes are not assigned. 21141-equivalent procedures map to ICD-10-PCS root operations Division (osteotomy cuts), Reposition (segment mobilization and repositioning), and Insertion (fixation hardware). The principal diagnosis and CC/MCC burden determine the MS-DRG assignment.

Head & Neck Procedure DRGs — Primary Assignment for Orthognathic Surgery

MS-DRG	Description	Approx. Relative Weight
168	Major Head & Neck Procedures w/ MCC	~3.8–4.2
169	Major Head & Neck Procedures w/ CC	~2.5–2.9
170	Major Head & Neck Procedures w/o CC/MCC	~1.8–2.1

Ear, Nose, Mouth & Throat — Alternative DRG

MS-DRG	Description	Approx. Relative Weight
154	Other Ear, Nose, Mouth & Throat OR Procedures w/ MCC	~3.1–3.6
155	Other Ear, Nose, Mouth & Throat OR Procedures w/ CC	~2.0–2.4
156	Other Ear, Nose, Mouth & Throat OR Procedures w/o CC/MCC	~1.4–1.7

Musculoskeletal — Facial Bone Procedures

MS-DRG	Description	Approx. Relative Weight
039	Extracranial Procedures w/ MCC	~3.2–3.8
040	Extracranial Procedures w/ CC	~2.0–2.4
041	Extracranial Procedures w/o CC/MCC	~1.4–1.8

DRG Optimization — 21141 Case Profile

Orthognathic surgery patients (21141 and combined bimaxillary cases) are typically young and healthy — a demographic that naturally generates fewer comorbidities and often lands in the lowest DRG tier (w/o CC/MCC). High-yield documentation and query opportunities:

• Acute blood loss anemia (D62) — Blood loss in bimaxillary surgery (Le Fort I + BSSO) commonly exceeds 300–500 mL; if transfusion is given or hemoglobin drops significantly and clinical documentation supports anemia → D62 (CC in some groupers — verify with your facility grouper)
• OSA (G47.33) — Many orthognathic and MMA patients have documented or undiagnosed OSA; if documented by the provider, code it
• Malnutrition (E44.0, E43) — Cleft patients and those with long-standing malocclusion-related eating difficulty; review dietary assessments → CC/MCC capture
• Nausea and vomiting requiring IV management — Common postoperative issue with nasotracheal intubation and prolonged anesthesia; document if IV antiemetics and nutritional support required
• Airway edema / respiratory monitoring — If prolonged intubation, tracheotomy, or significant postoperative respiratory monitoring required → query for J96.00 (MCC)
• Hypertension with perioperative management — I10 if documented and managed

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🌳 CPT Code Tree — Le Fort Osteotomy & Orthognathic Surgery Family

Le Fort I Osteotomy Family — Maxillary Reconstruction
│
├── Single Piece — No Bone Graft
│     └── 21141 ← LE FORT I, SINGLE PIECE, NO GRAFT (THIS CODE)
│           └── Standard: impaction, advancement, setback; whole maxilla as one unit
│
├── Two-Piece — No Bone Graft
│     └── 21142 — Le Fort I, two pieces (midline or parasagittal segmentation)
│           └── Arch width correction; independent repositioning of two halves
│
├── Three or More Pieces — No Bone Graft
│     └── 21143 — Le Fort I, three or more pieces
│           └── Multiple interdental osteotomies; complex multiplanar arch correction
│
├── Single Piece — WITH Bone Graft
│     └── 21145 — Le Fort I, single piece, with bone graft (includes obtaining graft)
│           └── Downgraft with gap; graft harvest bundled
│
├── Two-Piece — WITH Bone Graft
│     └── 21146 — Le Fort I, two pieces, with bone graft
│
└── Three or More Pieces — WITH Bone Graft
      └── 21147 — Le Fort I, three or more pieces, with bone graft

Higher-Level Le Fort Osteotomies (Craniofacial — Less Common)
├── 21150 — Le Fort II, anterior intrusion
├── 21151 — Le Fort II, any direction
├── 21154 — Le Fort III, without bone graft
├── 21155 — Le Fort III, with bone graft
└── 21160 — Le Fort III, with bone graft + distraction advancement device

Mandibular Procedures (Commonly Paired with [[21141]])
├── 21195 — BSSO, without rigid fixation (historical)
├── 21196 — BSSO, with internal rigid fixation ← Most common pair with 21141
├── 21193 — Mandibular rami reconstruction, bilateral, with bone grafts
└── 21194 — Mandibular rami reconstruction, unilateral, with bone graft

Genioplasty (Chin — Frequently Added to Bimaxillary Surgery)
├── 21120 — Genioplasty, augmentation (autogenous or alloplastic)
├── 21121 — Genioplasty, sliding osteotomy, single piece ← Most common genioplasty type
├── 21122 — Genioplasty, sliding osteotomy, 2 or more pieces
├── 21123 — Genioplasty, sliding osteotomy with bone graft augmentation
├── 21125 — Augmentation, mandibular body/angle; prosthetic material
└── 21127 — Augmentation, mandibular body/angle; with bone graft

Nasal Airway (Separately Reportable if Distinct Indication)
├── 30520 — Septoplasty (distinct, separately documented)
├── 30130 — Excision inferior turbinate, partial or complete
└── 30140 — Submucous resection inferior turbinate, partial or complete

TMJ — Associated Procedures (If Simultaneous)
├── 21240 — Arthroplasty, TMJ, with or without autograft
├── 21242 — Arthroplasty, TMJ, with allograft
├── 21243 — Arthroplasty, TMJ, with prosthetic joint replacement
└── 21244 — Reconstruction of mandibular condyle with bone and cartilage autografts

Bone Graft (Separately Reportable if Distinct from Le Fort I Gap Fill — Verify)
├── 20900 — Bone graft, minor or small
└── 20902 — Bone graft, major or large

Surgical Splint (Separately Reportable)
└── 21085 — Impression and custom preparation, occlusal device (surgical splint)

---

🗂️ ICD-10-PCS Context (Inpatient Coding)

Inpatient Coder Note (CIC Relevance)

In the inpatient acute care setting, 21141 is not assigned. All procedures are coded in ICD-10-PCS. The Le Fort I osteotomy with single-piece maxillary repositioning and internal fixation involves at least three distinct root operations, each requiring a separate ICD-10-PCS code per side.

ICD-10-PCS Root Operations for 21141-Equivalent Procedure

Step 1 — Osteotomy of the Maxilla (Bilateral Le Fort I Cuts):

Axis	Right Maxilla	Left Maxilla
Section	0 – Medical & Surgical	0 – Medical & Surgical
Body System	N – Head and Facial Bones	N – Head and Facial Bones
Root Operation	8 – Division	8 – Division
Body Part	0 – Maxilla, Right	1 – Maxilla, Left
Approach	0 – Open	0 – Open
Device	Z – No Device	Z – No Device
Qualifier	Z – No Qualifier	Z – No Qualifier

Division (8) = Osteotomy Without Bone Removal

The Le Fort I cuts divide the maxilla without removing it — this is Division (8). Assign separate Division codes for right and left maxilla, as each side involves independent osteotomies even though the segment moves as one unit.

Step 2 — Repositioning of the Maxillary Segment:

Axis	Value
Section	0 – Medical & Surgical
Body System	N – Head and Facial Bones
Root Operation	S – Reposition
Body Part	0 – Maxilla, Right AND 1 – Maxilla, Left
Approach	0 – Open
Device	Z – No Device
Qualifier	Z – No Qualifier

Reposition (S) — Captures the Mobilization and Movement

Reposition (S) is coded for the act of moving the maxillary segment to its corrected position. Although the single-piece Le Fort I moves the maxilla as one unit, some facilities assign Reposition for each anatomical body part designation (right and left maxilla). Follow your facility’s ICD-10-PCS coding guidelines and query resources for bilateral body part coding conventions in the Head and Facial Bones body system.

Step 3 — Insertion of Internal Fixation Device:

Axis	Value
Section	0 – Medical & Surgical
Body System	N – Head and Facial Bones
Root Operation	H – Insertion
Body Part	0 – Maxilla, Right AND 1 – Maxilla, Left
Approach	0 – Open
Device	4 – Internal Fixation Device
Qualifier	Z – No Qualifier

Complete ICD-10-PCS Code Set — Single Le Fort I (21141-Equivalent)

Minimum 4–6 ICD-10-PCS codes for a single 21141:

1. Division, Maxilla Right — Open
2. Division, Maxilla Left — Open
3. Reposition, Maxilla Right — Open
4. Reposition, Maxilla Left — Open
5. Insertion, Internal Fixation Device, Maxilla Right — Open
6. Insertion, Internal Fixation Device, Maxilla Left — Open

For bimaxillary surgery (21141 + 21196): Add all BSSO codes (Division, Reposition, Insertion × bilateral mandible rami) → minimum 12 ICD-10-PCS codes for the combined procedure. Under-coding complex bimaxillary cases to 2–3 PCS codes is a systemic inpatient coding error.

Nasal Septum — Separate ICD-10-PCS Code?

The nasal septum osteotomy performed as part of the Le Fort I downfracture is generally considered integral to the Le Fort I approach in ICD-10-PCS coding — a separate Division code for the septum is typically not assigned. However, if a distinct septoplasty with submucosal resection is performed for a separate indication (and CPT 30520 was separately billed), a separate ICD-10-PCS code for the septum manipulation may be appropriate. Align ICD-10-PCS coding with the CPT/operative report documentation.

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📝 Coding Examples

Example 1 — Isolated Le Fort I for Maxillary Hypoplasia, Class III (Standard Case)

Clinical Scenario: 23-year-old female with skeletal Class III malocclusion and maxillary hypoplasia (SNA 77°, SNB 82°, ANB –5°). Twenty months of pre-surgical orthodontics completed. Undergoes Le Fort I osteotomy: single-piece maxillary advancement 6 mm and impaction 2 mm. Four titanium miniplates placed (bilateral piriform rims and zygomaticomaxillary buttresses). No bone graft required. No mandibular surgery performed.

CPT Code:

• 21141 — Le Fort I, single piece, movement in any direction (advancement + impaction; no graft)

ICD-10-CM:

• M26.02 — Maxillary hypoplasia (principal)
• M26.213 — Malocclusion, Angle’s class III (additional)

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Example 2 — Bimaxillary Orthognathic Surgery (Le Fort I + BSSO) — Most Common Combination

Clinical Scenario: 27-year-old male with combined maxillomandibular deformity — skeletal Class III with maxillary hypoplasia and mandibular hyperplasia. Bimaxillary surgery: Le Fort I, single piece, advancement 5 mm and impaction 3 mm, four miniplates; BSSO mandibular setback 8 mm, three bicortical screws per side. Total OR time: 5 hours 40 minutes.

CPT Codes:

• 21141 — Le Fort I, single piece (maxillary component)
• 21196 — BSSO with internal rigid fixation (mandibular component) (modifier -51)

ICD-10-CM:

• M26.02 — Maxillary hypoplasia (principal — primary jaw anomaly driving maxillary surgery)
• M26.03 — Mandibular hyperplasia (additional — mandibular component)
• M26.213 — Malocclusion, Angle’s class III (additional)

---

Example 3 — MMA for Obstructive Sleep Apnea (Le Fort I + BSSO)

Clinical Scenario: 45-year-old male with severe OSA (AHI 58, Epworth Sleepiness Scale 18); failed CPAP trial (14 months; non-compliant due to claustrophobia and mask leak); BMI 26.4; cephalometric evaluation confirms bilateral retrognathia (SNA 78°, SNB 74°) with reduced posterior airway space (11 mm). Undergoes MMA: Le Fort I advancement 10 mm (single piece; four miniplates; no graft); BSSO advancement 12 mm (bicortical screws bilaterally). Pre-authorization obtained.

CPT Codes:

• 21141 — Le Fort I, single piece (MMA maxillary component)
• 21196 — BSSO with internal rigid fixation (MMA mandibular component) (modifier -51)

ICD-10-CM:

• G47.33 — Obstructive sleep apnea (adult) (principal — primary surgical indication)
• M26.02 — Maxillary hypoplasia (additional — anatomic basis)
• M26.04 — Mandibular hypoplasia (additional — anatomic basis)
• R06.83 — Snoring (additional — symptom)

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Example 4 — Bimaxillary Surgery with Genioplasty (Three-Code Case)

Clinical Scenario: 25-year-old female with Class II skeletal malocclusion, maxillary excess (vertical), and chin deficiency. Le Fort I impaction 4 mm (single piece; four miniplates; no graft); BSSO advancement 5 mm (bicortical screws bilaterally); simultaneous sliding genioplasty advancement 6 mm (single piece, rigid fixation).

CPT Codes:

• 21141 — Le Fort I, single piece (maxillary impaction)
• 21196 — BSSO with rigid fixation (modifier -51)
• 21121 — Genioplasty, sliding osteotomy, single piece (modifier -51; modifier -59 — distinct symphyseal site)

ICD-10-CM:

• M26.01 — Maxillary hyperplasia (principal — vertical excess)
• M26.04 — Mandibular hypoplasia (additional — retrognathia)
• M26.212 — Malocclusion, Angle’s class II (additional)
• M26.09 — Other specified anomalies of jaw size (chin deficiency — additional)

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Example 5 — Post-Cleft Le Fort I Advancement (High Complexity — Modifier 22)

Clinical Scenario: 19-year-old female with history of complete unilateral cleft lip and palate (UCLP) repaired at age 14 months (lip) and 18 months (palate). Now with severe maxillary hypoplasia (SNA 67°, Class III) secondary to palatal scarring. Le Fort I advancement 9 mm performed through scarred vestibular tissue and restrictive palatal mucosa. Pterygomaxillary dysjunction required multiple osteotome passes bilaterally due to fibrosis. Marked intraoperative bleeding from scarred tissue. Total OR time: 4 hours 55 minutes (Le Fort I alone). No graft required (advancement only; no gap). Modifier -22 requested with cover letter and operative note documentation.

CPT Codes:

• 21141 with modifier -22 — Le Fort I, single piece; significantly increased complexity (prior cleft repair, scarred anatomy, prolonged OR time)
• (If BSSO also performed — 21196 with modifier -51)

ICD-10-CM:

• M26.02 — Maxillary hypoplasia (principal)
• Q37.9 — Unspecified cleft palate with cleft lip (additional — underlying etiology)
• M26.213 — Malocclusion, Angle’s class III (additional)

---

Example 6 — Le Fort I with Simultaneous Septoplasty (Separately Documented)

Clinical Scenario: 28-year-old male undergoing Le Fort I advancement (single piece) for maxillary hypoplasia and Class III malocclusion. Preoperative evaluation independently documented deviated nasal septum with left nasal obstruction causing significant mouth breathing and sleep disturbance — separately evaluated by ENT. Operative plan and pre-authorization include Le Fort I AND functional septoplasty. Operative report contains distinct paragraphs for Le Fort I procedure and septoplasty (submucous resection with cartilage scoring, separate from routine Le Fort I septal osteotomy). Two separate CPT codes billed.

CPT Codes:

• 21141 — Le Fort I, single piece (maxillary advancement)
• 30520 — Septoplasty (modifier -51; modifier -59 — distinct functional indication, distinct documentation)

ICD-10-CM:

• M26.02 — Maxillary hypoplasia (principal — orthognathic indication)
• J34.2 — Deviated nasal septum (additional — distinct septoplasty indication)
• J34.89 — Other specified disorders of nose (nasal obstruction — supporting septoplasty)
• M26.213 — Malocclusion, Angle’s class III (additional)

Septoplasty Documentation Must Stand Alone

The 30520 claim alongside 21141 will face NCCI scrutiny. The operative report must include a distinct section describing the septoplasty that is clearly separate from the Le Fort I approach. If reviewers cannot clearly distinguish the septoplasty from the routine Le Fort I nasal septum osteotomy, the claim will be denied. Many OMFS surgeons dictate a combined operative note — request a separate dictation or distinct headings for each procedure.

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Example 7 — Return to OR, Plate Fracture and Maxillary Relapse (Global Period)

Clinical Scenario: POD #19 following 21141 (Le Fort I advancement). Patient notes acute change in bite. Imaging shows fracture of left piriform rim miniplate and 2 mm inferior relapse of left maxillary segment. Returned to OR — fractured plate removed, maxilla re-manipulated to correct position, new miniplate placed.

CPT Code:

• 21141 with modifier -78 — Return to OR for related procedure during postoperative period (hardware failure and segment relapse)

ICD-10-CM:

• T84.123A — Displacement of internal fixation device of bone of face, initial encounter
• M26.02 — Maxillary hypoplasia (underlying condition from index surgery)

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Example 8 — Post-Traumatic Malunited Le Fort I Fracture

Clinical Scenario: 31-year-old male who sustained a Le Fort I fracture in a motor vehicle accident 8 months ago, treated non-operatively, now presents with significant malocclusion (anterior open bite) and midface retrusion. Corrective Le Fort I osteotomy performed through malunited fracture line, which required extensive osteotome work to re-mobilize the fused segment; significant fibrosis and obliterated tissue planes noted. Single-piece advancement 7 mm and impaction 2 mm; four miniplates placed.

CPT Codes:

• 21141 with modifier -22 — Le Fort I, single piece; significantly increased complexity (post-traumatic malunion with fibrosis; prolonged osteotome mobilization required; OR time 4 hours 10 minutes for Le Fort I alone — cover letter attached)

ICD-10-CM:

• M26.02 — Maxillary hypoplasia (post-traumatic; principal)
• S02.411A — Le Fort I fracture (use sequela 7th character “S” for healed/malunited state) — S02.411S
• M26.221 — Anterior open bite (additional — resulting deformity)
• W03.XXXA — Other fall on same level due to collision with or pushing by another person (external cause if applicable)

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⚠️ Common Coding Pitfalls

• 21141 vs. 21145 — the bone graft decision: The most critical code selection branch. Read the operative report for graft harvest and placement documentation. Downgraft without graft documentation → 21141; downgraft WITH bone graft → 21145. Assigning 21141 when a graft was placed significantly under-codes the procedure (~3.5 wRVU difference).
• 21141 vs. 21142/21143 — count the pieces: Read the operative note for any mention of interdental osteotomies, midline cuts, parasagittal osteotomies, or segmentation of the maxilla. Any additional cut creating a second mobile piece → 21142. Multiple cuts with three or more segments → 21143. Never assume single-piece when the surgeon describes additional osteotomies without explicitly stating single-piece movement.
• Le Fort I is NEVER bundled into BSSO: The two codes (21141 and 21196) are always separately reportable in bimaxillary surgery. Billing only 21196 for a combined bimaxillary case loses the entire Le Fort I wRVU — a significant revenue loss.
• Alar cinch suture is NOT a separately billable soft tissue procedure: This is integral to Le Fort I wound closure. Do not bill rhinoplasty or soft tissue suspension codes for this maneuver.
• Septoplasty bundling trap: The nasal septum osteotomy in the Le Fort I is bundled. Septoplasty (30520) is only separately billable when there is a distinct, separately documented, preoperatively diagnosed septal deviation with independent functional indication. Without this documentation, all payers will deny 30520 as bundled.
• Bone graft NOT bundled in 21141: Unlike 21145 which explicitly includes obtaining the graft, 21141 has no graft bundling language. However, when a Le Fort I is coded as 21141 (no graft required), there should be no bone graft harvest billed — if a graft was used, the code should be 21145. Do not bill both 21141 + 20902 — this is a compliance risk.
• Inpatient setting: Never assign 21141 for inpatient acute care. Use ICD-10-PCS with root operations Division (8), Reposition (S), and Insertion (H) for bilateral maxilla — minimum 4–6 codes for Le Fort I alone; 10–12+ for combined bimaxillary surgery.
• Modifier -22 requires specific documentation: A prior history of cleft palate or trauma mentioned briefly in the preoperative assessment is NOT sufficient for modifier -22. The operative note must describe specific technical challenges encountered intraoperatively — tissue planes, bleeding, instrument requirements, inability to use standard technique. Include actual OR time compared to expected range for the code.
• Medical necessity documentation for commercial payers: Orthognathic surgery is the most frequently denied category of elective maxillofacial surgery. Ensure cephalometric analysis, functional impairment documentation, orthodontic records, and clinical photographs are assembled before surgery and attached to every prior authorization request.
• OSA-driven MMA denials: CPAP failure documentation is the single most commonly missing element. Confirm objective compliance data (CPAP machine download) or documented intolerance in the record before claiming MMA-for-OSA on any commercial or Medicare plan.

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📚 Brief Source References

^{AMA CPT Professional Edition 2025, codes 21141–21160 and musculoskeletal head section guidelines CMS Medicare Physician Fee Schedule Final Rule 2025 – Work RVU and payment indicator files (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched) CMS NCCI Policy Manual for Medicare Services, Chapter 9: Surgery – Musculoskeletal System, 2025 CMS MS-DRG Definitions Manual v41 FY2024 – Major Head & Neck DRGs 168–170; ENT DRGs 154–156 ICD-10-PCS Official Guidelines for Coding and Reporting FY2025 – Section B3 Root Operations: Division (8), Reposition (S), Insertion (H), B3.4a Diagnostic qualifier ICD-10-CM Official Guidelines for Coding and Reporting FY2025 – Section I.C.13 Musculoskeletal; Neoplasms Section I.C.2 Proffit WR, White RP, Sarver DM. Contemporary Treatment of Dentofacial Deformity. Mosby 2003 – Maxillary Surgery chapter Bell WH. Modern Practice in Orthognathic and Reconstructive Surgery. Saunders 1992 – Le Fort I Osteotomy: Surgical Technique Le Fort R. Etude expérimentale sur les fractures de la mâchoire supérieure. Rev Chir Paris 1901;23:208–227, 360–379, 479–507 AAOMS Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery – Orthognathic Surgery section. 6th ed. 2017 AAPC CPC/CIC Study Guide – Musculoskeletal Surgery: Head; Orthognathic Surgery chapter}