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21315 - Lefort 1 Guide 2

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🩺 CPT Code 21315: Documentation & Billing Guide

Osteotomy, Maxilla, with Synchronous Repositioning of Segments and Soft Tissues (LeFort I)

Last Updated: February 2026
Status: 2025 Medicare Fee Schedule Compliant
Specialty Tags:

QUICK REFERENCE

ElementDetails
Code21315
Code TypeSurgical Procedure - Maxillofacial/Orthognathic Surgery
Procedure TypeLeFort I maxillary osteotomy with maxillary repositioning
Global Period090 days (major surgical procedure)
Work RVU (2025)7.46 RVU
Practice Expense RVU (2025, Non-Facility)3.89 RVU
Practice Expense RVU (2025, Facility)2.58 RVU
Malpractice RVU (2025)0.82 RVU
Total RVU (2025, Non-Facility)12.17 RVU
Total RVU (2025, Facility)10.86 RVU
2025 Medicare Fee (Non-Facility)~32.3465 CF × GPCI)
2025 Medicare Fee (Facility)~32.3465 CF × GPCI)
Conversion Factor (2025)$32.3465
Estimated Commercial Insurance$1,200 - 2,000
Global Period IncludesPre-operative visits, surgery, post-operative visits (90 days)
Common Place of ServiceHospital inpatient (21), Hospital outpatient (22), ASC (24)
SpecialtyOral & Maxillofacial Surgery, Plastic Surgery, Orthodontics (surgical component)
Surgical TimeTypically 2-3 hours

📋SHORT DEFINITION

CPT 21315 describes a LeFort I maxillary osteotomy with repositioning of the maxilla (upper jaw). This major surgical procedure involves cutting the maxilla above the teeth with synchronous repositioning of the maxillary bone segments and soft tissues to correct skeletal malocclusion, jaw deformities, sleep apnea, or functional/esthetic problems.

LONG DEFINITION

CPT 21315 represents a comprehensive LeFort I osteotomy, a major orthognathic surgical procedure that surgically repositions the entire maxilla (upper jaw bone). This is one of the most common orthognathic procedures performed to correct significant skeletal jaw discrepancies.

Surgical Technique - LeFort I Osteotomy

Classic LeFort I Approach:

  • Horizontal bone cut made above the dental apices (roots) in the maxilla
  • Vertical cuts made on the lateral walls of the maxilla (between maxilla and zygoma/cheekbone)
  • Pterygoid plates detached posteriorly to allow maxillary mobility
  • Entire maxilla mobilized as a single unit
  • Maxilla repositioned in three-dimensional space (forward, backward, rotation, vertical adjustment)
  • New position secured with rigid internal fixation (plates, screws)
  • Soft tissues redraped and sutured

Key Features (Synchronous Repositioning of Segments and Soft Tissues):

  • “Synchronous repositioning” = maxilla AND soft tissues repositioned together during same procedure
  • Includes adjustment of palatal vault, alveolar segments, and attached soft tissues
  • Maintains neurovascular integrity

Common Clinical Indications:

For Maxillary Advancement:

  • Maxillary hypoplasia (underdeveloped upper jaw)
  • Anterior open bite (teeth don’t meet in front)
  • Class II malocclusion (lower jaw appears too prominent relative to upper jaw)
  • Sleep apnea (advancing maxilla expands airway)
  • Mid-face deficiency (underprojected cheekbones/upper jaw)

For Maxillary Setback:

  • Maxillary prognathism (overprojected upper jaw)
  • Severe Class III malocclusion
  • Anterior protrusion

For Maxillary Rotation/Vertical Adjustment:

  • Cant (tilted occlusal plane)
  • Vertical excess or deficiency
  • Asymmetry

For Other Indications:

  • Cleft palate sequelae (maxillary development abnormality)
  • Hemifacial microsomia
  • Combination procedures (often combined with mandibular surgery 21436, 21470)

Procedure Duration: Typically 2-3 hours

Key Distinctions:

  • CPT 21310 = Osteotomy, maxilla, NOT requiring synchronous repositioning—lower RVU (3.91)
  • CPT 21315 = Osteotomy, maxilla, WITH synchronous repositioning of segments and soft tissues—highest RVU (7.46), most complex
  • CPT 21320 = Osteotomy, maxilla, with LeFort III type correction (more extensive)—separate code

Important Note: CPT 21315 is the standard code for most LeFort I procedures with maxillary repositioning. It is often billed in combination with mandibular osteotomy codes (21436, 21470) for comprehensive orthognathic correction.

WORK RELATIVE VALUE UNITS (wRVUs) & COMPONENTS

Work RVU Breakdown (2025)

RVU ComponentValueWhat It Represents
Work RVU7.46Physician work, technical skill, time, decision-making (major surgery)
Practice Expense RVU (non-facility)3.89Surgical instruments, surgical hardware (plates, screws), staff support
Practice Expense RVU (facility)2.58Lower due to hospital/ASC equipment overhead
Malpractice RVU0.82Malpractice insurance and liability (major surgical procedure)
TOTAL RVU (non-facility)12.17Total relative value units
TOTAL RVU (facility)10.86Total relative value units (lower)

RVU Conversion to Dollar Amount (2025)

Formula: RVU × Conversion Factor (CF) × Geographic Practice Cost Index (GPCI) = Payment

2025 Medicare Conversion Factor: $32.3465

Typical Calculations (Non-Facility, GPCI = 1.0):

  • 7.46 wRVU × 241.23** (work component)
  • 3.89 PE RVU × 125.91** (practice expense)
  • 0.82 MP RVU × 26.52** (malpractice)
  • Total = ~$393.75 per procedure (non-facility, GPCI 1.0)

Facility-Based (Hospital OR, ASC):

  • 7.46 wRVU × 241.23** (work component, same)
  • 2.58 PE RVU × 83.53** (practice expense, lower)
  • 0.82 MP RVU × 26.52** (malpractice, same)
  • Total = ~$351.23 per procedure (facility, GPCI 1.0)

Real-World Range (2025):

  • Non-Facility (Office OR or Hospital): 455 (depending on GPCI)
  • Facility-Based (Hospital OR, ASC): 410 (lower PE RVU)

GLOBAL PERIOD

Global Period Status: 090 days (90-Day Global Period)

What This Means:

  • CPT 21315 is a major surgical procedure with a 90-day global period
  • Includes ALL pre-operative and post-operative care:
    • All office visits within 90 days before surgery
    • Pre-operative diagnostic imaging and consultations
    • The surgery itself
    • All post-operative visits within 90 days (routine follow-up, wound checks, etc.)
    • Hospital/facility care related to the procedure
    • Post-operative complications related to the surgery
    • Post-operative radiographs (cephalometric, panoramic) related to surgical outcome
  • One flat fee covers all bundled services
  • Separate payment only for unrelated E/M during global period (use modifier -24)

Billing Implications:

  • Cannot bill separate office visit codes within 90 days of surgery for related care - included in global fee
  • CAN bill separate codes for unrelated problems during global period with modifier -24 (unrelated E/M)
  • CAN bill separate codes for additional procedures performed same day (e.g., mandibular surgery 21436) with both RVU values paid
  • Global period does NOT include hospitalization facility charges; hospital bills separately

Global Period Timeline:

  • Pre-operative period: Day before surgery through surgery date
  • Post-operative period: Day of surgery through 90 days after surgery

DOCUMENTATION REQUIREMENTS FOR 21315

Minimum Documentation Components

Pre-Operative Assessment:

Chief Complaint/Indication:

  • Jaw deformity, malocclusion, functional impairment, sleep apnea, mid-face deficiency, or combination
  • Duration and severity of symptoms

History of Present Illness:

  • Onset of jaw deformity, growth history
  • Functional complaints (chewing difficulty, speech, breathing, sleep issues)
  • Prior orthodontic treatment
  • Prior jaw surgery (if any)
  • Trauma history affecting jaw development

Physical Examination - Critical Measurements:

  • Occlusal Relationships:
    • Overjet (forward-backward relationship of front teeth)
    • Overbite (vertical overlap of front teeth)
    • Posterior bite relationship (Class I, II, III)
    • Midline deviation
  • Facial Proportions:
    • Anterior-posterior maxillary position relative to cranium
    • Vertical dimensions (facial height assessment)
    • Facial symmetry (asymmetry documentation)
  • Soft Tissue Assessment:
    • Lip position, fullness, relationship to teeth
    • Smile analysis
    • Profile assessment
  • Airway Assessment: If sleep apnea indication, airway obstruction documented

Imaging - CRITICAL:

  • Lateral cephalometric radiograph: Shows:
    • SNA angle (maxillary position relative to anterior cranial base; normal ~82°)
    • SNB angle (mandibular position relative to anterior cranial base; normal ~80°)
    • ANB angle (jaw relationship; Class I ~2°, Class II >4°, Class III <0°)
    • Vertical dimensions (GOAOR, MP to SN)
    • Anterior open bite measurements (if present)
    • Posterior facial height
  • Panoramic radiograph: Shows:
    • Dental status (missing teeth, roots)
    • Bone height/periodontal status
    • Bilateral symmetry assessment
  • CT scan: May be obtained for surgical planning (3D assessment of bone anatomy, asymmetry)
  • Functional imaging: Sleep study if OSA indication

Informed Consent Documentation:

  • Risks: Bleeding, infection, relapse, TMJ dysfunction, numbness (inferior alveolar nerve injury), asymmetry, need for revision
  • Benefits: Improved occlusion, airway, esthetics, function
  • Alternatives: Orthodontics alone (if mild), implants, non-surgical management

Baseline Photographs:

  • Pre-operative: Frontal, lateral, oblique, intraoral views (standard of care)

Surgical Planning Documentation:

  • Predicted surgical movements (mm forward/back, rotation, vertical changes)
  • Expected post-operative occlusion
  • Coordination with mandibular surgery (if combined)

Surgical Procedure Documentation:

Technique - LeFort I Osteotomy:

  • Approach: Intraoral incision location, extent
  • Exposure: Maxillary sidewalls exposed bilaterally
  • Horizontal osteotomy: Made above dental apices (height documented)
  • Vertical cuts: Locations of lateral maxillary cuts (between maxilla and zygoma), extent
  • Pterygoid plates: Separated (critical for maxillary mobility)
  • Maxilla mobilized: Confirmed to be mobile as single unit
  • Repositioning: Direction and amount of maxillary movement:
    • Anterior-posterior: mm forward or backward
    • Vertical: mm raised or lowered
    • Rotation: degrees of rotation to correct cant
    • Bilateral symmetry confirmed
  • Fixation: Type and location:
    • Bilateral rigid fixation with titanium L-plates or hybrid plates
    • Number and location of plates
    • Screw count and positions (typically 4-6 plates total, multiple screws each)
    • Bilateral confirmation of stability
  • Soft tissue management:
    • Maxillary tuberosity repositioning
    • Nasal base positioning (if affected)
    • Soft palate management
    • Incision closure technique and materials
  • Intraoperative monitoring:
    • Nerve function assessment (infraorbital nerve, mental nerve)
    • Occlusal relationship verification (intermax fixation or wafers)
    • Bilateral symmetry verification
  • Intraoperative complications: None vs. specific issues (bleeding, nerve injury, inadequate mobilization)
  • Operative time: Total time in OR
  • Estimated blood loss: Important for post-op management

Post-Operative Plan:

  • Occlusion: Final occlusal relationship, intermax fixation status (if applicable)
  • Dietary restrictions: Soft diet for [X] weeks, activity limitations
  • Medications: Pain management, antibiotics, antiemetics
  • Jaw movement: Restrictions or guidance on mouth opening
  • Followup Schedule: Post-op appointments (typically day 1, week 1, week 3, 6 weeks, 3 months, 6 months)
  • Imaging: Post-operative cephalometric radiographs (typically 6-12 weeks post-op to assess healing and final position)
  • Orthodontist coordination: If post-operative orthodontics planned
  • Hardware management: If plates will be removed (typically left in place permanently)

Post-Operative Notes (Included in Global Period):

  • Wound status: Healing, swelling, ecchymosis, intraoral incision status
  • Maxillary position: Assessment of anterior-posterior projection, vertical position, symmetry
  • Occlusal relationships: Bite verification, midline alignment
  • Neurosensory status: Infraorbital nerve function, numbness extent
  • Complications: Infection signs, bleeding, TMJ dysfunction, unexpected asymmetry
  • Hardware assessment: Plate/screw stability, incision integrity

BILLING RULES & GLOBAL PERIOD MANAGEMENT

Global Period Coverage (CRITICAL)

What’s Included in the 90-Day Global Fee:

✓ Included (NO separate billing):

  • All pre-operative E/M visits
  • Pre-operative imaging interpretation
  • Pre-operative surgical planning consultations
  • The surgical procedure itself
  • All post-operative office visits for related care (wound checks, bite verification, swelling assessment)
  • Hospital/facility charges (though hospital bills separately)
  • Routine post-operative complication management
  • Suture removal
  • Post-operative radiographs related to surgical outcome

✗ NOT Included (Can bill separately with appropriate modifier):

  • Unrelated E/M during global period (use modifier -24)
  • Unrelated procedures during global period (use modifier -24 or -59)
  • Concurrent mandibular surgery (e.g., 21436, 21470)—billed with both RVU values
  • Implant removal or revision after global period

Modifiers for Global Period

ModifierDescriptionWhen to Use
-24Unrelated E/M during postoperative periodWhen billing E/M for unrelated problem during 90-day period
-59Distinct procedural serviceWhen performing unrelated procedure same day
--RTLeft/Right sideFor side-specific procedures (rarely used with 21315; bilateral by nature)
-50Bilateral procedureNot typically used with 21315 (already bilateral)
None (most common)Standard billingRoutine unilateral or bilateral LeFort I

Common Billing Combinations:

  • 21315 + 21436 (LeFort I + bilateral sagittal split osteotomy)—both billed separately with both RVU values
  • 21315 + 21390 (LeFort I + genioplasty)—both billed separately

MEDICARE RULES FOR 21315

CMS-Specific Rules & Policies

1. Global Period Management (Critical)

  • 90-day global period is standard for all major orthognathic procedures
  • All routine post-op care included in global fee
  • Unrelated services must use modifier -24 to be separately billed

2. Facility vs. Non-Facility Billing

  • Non-Facility (office-based OR): Higher PE RVU (3.89), higher reimbursement (~$394)
  • Facility (hospital OR, ASC): Lower PE RVU (2.58), lower reimbursement (~$351)
  • Facility bills separately for facility charges (hospital or ASC facility fee)

3. Concurrent Mandibular Surgery (CRITICAL)

  • 21315 + 21436 (bilateral sagittal split) can be billed same day for combined jaw correction
  • Both procedures payable; both have 90-day global periods (coincide)
  • Both codes billed with both RVU values separately
  • Most common combination for comprehensive orthognathic correction

4. Surgical Hardware Included

  • Titanium plates, screws, fixation devices are included in 21315 RVU
  • Do NOT bill separately for surgical hardware
  • Hardware costs absorbed in procedure fee

5. Local Coverage Determinations (LCDs)

  • Most orthognathic procedures do not have specific NCDs
  • Many MACs have LCDs requiring pre-authorization
  • Verify your MAC for specific requirements and medical necessity criteria

LOCAL COVERAGE DETERMINATIONS (LCDs) & NATIONAL COVERAGE

National Coverage Determination (NCD)

There is NO specific NCD for CPT 21315 (LeFort I osteotomy).

General Medicare Coverage Policy:

  • Orthognathic procedures covered when performed for documented functional or medical necessity
  • Purely esthetic surgery not covered
  • Documentation must demonstrate:
    • Functional impairment (eating, breathing, speech)
    • OR documented sleep apnea corrected by surgery
    • OR significant esthetic deformity with functional component
    • OR documented skeletal asymmetry
  • Pre-authorization typically required

Local Coverage Determinations (LCDs) - MAC-Specific

LCDs vary by Medicare Administrative Contractor (MAC) jurisdiction.

Common LCD Requirements for 21315:

RequirementDetails
Medical NecessityFunctional impairment, sleep apnea, or skeletal asymmetry; not purely esthetic
Cephalometric AnalysisLateral cephalometric radiographs with specific measurements (SNA, SNB, ANB angles)
Diagnosis CodeICD-10 showing functional/medical indication (M26.8x for dentofacial anomalies, G47.33 for OSA, etc.)
Concurrent ProceduresIf combined with mandibular surgery, all procedures must be justified
Prior AuthorizationMost MACs require pre-auth for orthognathic procedures
Surgeon CredentialsBoard certification or specialty training in oral/maxillofacial surgery preferred
ImagingLateral cephalometric radiographs, panoramic radiographs, CT scan if asymmetry
Conservative Treatment FailedSome MACs require documentation that orthodontics alone inadequate

To Find Your MAC’s LCD:

  1. Go to CMS LCD Search Tool: https://www.cms.gov/cclc/lcd
  2. Enter your MAC jurisdiction
  3. Search for “orthognathic,” “LeFort,” “maxillary osteotomy”
  4. Review specific coverage criteria and authorization requirements

COMMON MODIFIERS & GLOBAL PERIOD RULES

Modifier -24 (Unrelated E/M During Post-Op Period)

Use when: Billing E/M for unrelated problem during 90-day global period

Example:

  • Patient has LeFort I on 2/15/2026 (90-day global ends 5/15/2026)
  • On 3/1/2026, patient develops unrelated infection (UTI) and returns for evaluation
  • Coding: 99213-24 for UTI (unrelated to LeFort I)
  • The 21315 global fee remains unchanged; separate E/M payment applies

Documentation requirement: E/M note must clearly document unrelated problem

Concurrent Procedures - 21315 + 21436 (Most Common Combination)

Use when: LeFort I (maxillary) AND bilateral sagittal split (mandibular) performed same day

Coding:

  • 21315 (LeFort I maxillary osteotomy) - billed with full RVU value
  • 21436 (bilateral sagittal split osteotomy, mandible) - billed with full RVU value
  • Both codes billed separately; both RVU values paid
  • Both carry 90-day global periods (coincide)
  • Total work RVU: 7.46 + 7.29 = 14.75 RVU (for combined procedure)
  • Total Medicare payment (non-facility): ~392 = ~$786

Documentation requirement: Both procedures must be documented separately in operative report with specific technique details for each

2025 REIMBURSEMENT INFORMATION

Medicare 2025 Fee Schedule

CPT 21315 - Osteotomy, Maxilla, with Synchronous Repositioning

CategoryValue
Work RVU7.46
Practice Expense RVU (non-facility)3.89
Practice Expense RVU (facility)2.58
Malpractice RVU0.82
Total RVU (non-facility)12.17
Total RVU (facility)10.86
Conversion Factor (2025)$32.3465
National Average Fee (Non-Facility, GPCI 1.0)$393.75
Estimated Range (Non-Facility)$365 - 455
National Average Fee (Facility, GPCI 1.0)$351.23
Estimated Range (Facility)$325 - 410

Year-Over-Year Comparison (2024 vs 2025)

Metric20242025Change
Work RVU7.467.46-
PE RVU (non-facility)3.893.89-
CF$33.2875$32.3465-2.8%
National Average (Non-Facility)~$405.16~$393.75-2.8%
Global Period090090-

Reason for fee decrease: 2.8% conversion factor reduction due to expiration of temporary 2024 increase.

Commercial Insurance & Medicaid Reimbursement (2025)

Commercial Insurance:

  • Typically pays 2-4× Medicare rates
  • Estimated 21315 payment: 2,000 (varies by payer)
  • Often requires pre-authorization
  • Some payers cover only if functional impairment documented

Medicaid:

  • Varies significantly by state
  • Estimated 21315 payment: 800 (state-dependent)
  • Many states do NOT cover orthognathic surgery (considered esthetic or elective)
  • States that do cover require functional documentation
  • Prior authorization typically required

Self-Pay/Cash Price:

  • Typically 8,000 depending on provider, location, complexity, surgeon experience

Maxillary Osteotomy Code Family (21310-21320)

CodeDescriptionComplexityRVU (Work)Global
21310Osteotomy, maxilla, NOT requiring synchronous repositioningLow-Moderate3.91090
21315Osteotomy, maxilla, WITH synchronous repositioning of segments and soft tissuesHigh7.46090
21320Osteotomy, maxilla, with LeFort III type correctionVery High8.13090

21315 vs Other Jaw Surgery Codes

CodeDescriptionRVU (Work)When Used
21315LeFort I (maxilla advancement/repositioning)7.46Most common maxillary correction; often combined with mandibular surgery
21320LeFort III (more extensive maxillary + midface correction)8.13Extensive facial deformity, hemifacial microsomia, cleft palate sequelae
21436Bilateral sagittal split osteotomy (mandible)7.29Most common mandibular correction; often combined with 21315
21470Anterior alveolar osteotomy (limited maxillary movement)4.66Limited anterior maxillary movement; less common

Most Common Combination: 21315 + 21436

Bimaxillary Orthognathic Surgery:

Element21315 (Maxilla)21436 (Mandible)Combined
Work RVU7.467.2914.75
Total RVU (non-facility)12.1711.6023.77
Medicare Payment (non-facility)~$394~$375~$769
Surgical Time1.5-2 hrs1.5-2 hrs3-4 hrs total
Global Period090 days090 daysBoth coincide (90 days)
Use CaseClass II or III with maxillary deficiencyClass III or asymmetry with mandibular excessComprehensive jaw correction

FREQUENTLY BILLED SCENARIOS FOR 21315

Scenario 1: LeFort I Maxillary Advancement for Class II Malocclusion

Patient: 28-year-old with Class II malocclusion, maxillary hypoplasia (underdeveloped upper jaw), anterior open bite, esthetic concern

Pre-Operative Assessment:

  • Cephalometric radiographs show:
    • SNA angle = 76° (normal ~82°; deficient by 6°)
    • SNB angle = 81° (normal)
    • ANB angle = -5° (Class II; should be ~2°)
    • Anterior open bite = 4mm
  • Clinical exam: Maxilla appears underprojected; lower jaw relatively prominent
  • Imaging: Panoramic radiographs show good bone height, no significant asymmetry
  • Functional: Difficulty chewing hard foods; speech slightly affected
  • Esthetic: Profile imbalance; lip support inadequate

Surgical Plan: LeFort I maxillary advancement 6mm anteriorly to improve maxillary projection and close anterior open bite

Procedure:

  • Intraoral incision made in vestibule above teeth
  • Maxillary sidewalls exposed bilaterally
  • Horizontal osteotomy made above dental apices
  • Vertical cuts made between maxilla and zygoma bilaterally
  • Pterygoid plates separated posteriorly
  • Maxilla mobilized and confirmed mobile as single unit
  • Maxilla advanced 6mm anteriorly; rotation adjusted to improve cant
  • Rigid fixation with bilateral titanium L-plates (4 plates total, 6 screws each = 24 screws total)
  • Occlusal relationship verified
  • Intraoral incisions closed

Post-Op: Soft diet × 4 weeks. Expect swelling peak at 48 hours, gradual reduction over 2-3 weeks. Sensation returns over 3-6 months.

Coding:

  • 21315 (LeFort I maxillary advancement)
  • Diagnosis: M26.81 (anterior relation anomaly), M26.01 (anteroposterior maxillary relation anomaly)

Scenario 2: Bimaxillary Surgery - LeFort I + Bilateral Sagittal Split (21315 + 21436)

Patient: 32-year-old with Class III malocclusion, mandibular prognathism (overdeveloped lower jaw), maxillary hypoplasia, significant esthetic concern

Pre-Operative Assessment:

  • Cephalometric radiographs show:
    • SNA = 78° (deficient)
    • SNB = 86° (excessive)
    • ANB = -8° (Class III)
    • Asymmetry noted with slight deviation
  • Clinical: Pronounced under-bite; chin appears very prominent
  • Functional: Difficulty chewing; speech affected
  • Orthodontics: Pre-operative orthodontics completed; teeth well-aligned within skeletal deformity

Surgical Plan: Combined orthognathic surgery:

  • LeFort I: Maxilla advanced 5mm anteriorly
  • Bilateral sagittal split: Mandible setback 8mm bilaterally

Procedure: Both procedures performed under same anesthesia in same operative session.

  • LeFort I completed first (maxillary advancement)
  • Bilateral sagittal split BSSO performed (mandibular setback)
  • Final occlusion verified with both jaws repositioned
  • All fixation secured bilaterally on both maxilla and mandible

Post-Op: Soft diet × 6 weeks. Jaw elastics × 2-3 weeks for guided healing.

Coding:

  • 21315 (LeFort I maxillary advancement) - Full RVU value
  • 21436 (bilateral sagittal split osteotomy, mandible) - Full RVU value
  • Total RVU payment: ~375 (21436) = ~$769
  • Diagnosis: M26.81 (anterior relation anomaly, Class III), M26.02 (anterior maxillary relation anomaly with mandibular prognathism)

Scenario 3: LeFort I for Sleep Apnea

Patient: 48-year-old with moderate obstructive sleep apnea (OSA), maxillary hypoplasia, failed CPAP tolerance

Pre-Operative Assessment:

  • Sleep study: AHI 22 (moderate OSA)
  • CPAP trial: Intolerant to mask pressure and noise
  • Cephalometric analysis shows:
    • Maxillary deficiency (SNA = 75°)
    • Retrognathic mandible (SNB = 78°)
    • Airway space reduced
  • ENT evaluation: No other upper airway obstruction identified
  • Esthetic: Secondary concern, but profile improvement expected

Surgical Plan: LeFort I maxillary advancement 7mm to expand airway space

Procedure: Standard LeFort I with maxillary advancement 7mm anteriorly

Post-Op: Post-operative sleep study scheduled 3 months post-op to assess improvement. Expected improvement in AHI and oxygen desaturation events.

Coding:

  • 21315 (LeFort I maxillary advancement for OSA)
  • Diagnosis: G47.33 (obstructive sleep apnea, moderate), M26.01 (maxillary deficiency)
  • Note: Medicare more likely to cover OSA indication vs. purely esthetic

Scenario 4: LeFort I for Cleft Palate Sequelae

Patient: 22-year-old with history of unilateral cleft lip and palate, repaired in childhood; now presents with maxillary hypoplasia, crossbite, anterior open bite

Pre-Operative Assessment:

  • Prior cleft surgery (LeFort I advancement for cleft patient with limited success; now requires re-do)
  • Cephalometric radiographs show posterior maxillary deficiency; anterior/posterior asymmetry
  • CT scan obtained: Shows maxillary bone deficiency and anatomic variation from prior cleft repair
  • Functional: Eating difficulty; speech velopharyngeal insufficiency (VPI) addressed post-surgically
  • Esthetic: Facial asymmetry; maxillary deficiency

Surgical Plan: LeFort I maxillary advancement with asymmetric repositioning to correct both anterior-posterior deficiency and asymmetry; coordinate with velopharyngeal insufficiency management

Procedure: LeFort I with careful attention to asymmetric repositioning; possible need for additional soft tissue management

Coding:

  • 21315 (LeFort I maxillary advancement)
  • Diagnosis: Q37.9 (cleft palate with cleft lip, unilateral), M26.8 (sequelae of cleft repair)

DOCUMENTATION TIPS FOR 21315

What to Document

✓ SHOULD INCLUDE:

  1. Indication for Surgery - Malocclusion (Class II, III, etc.), maxillary hypoplasia, asymmetry, sleep apnea, functional impairment
  2. Pre-Operative Cephalometric Analysis:
    • SNA angle with interpretation (normal ~82°)
    • SNB angle with interpretation (normal ~80°)
    • ANB angle with interpretation (normal ~2° for Class I)
    • Vertical dimensions (GOAOR, MP to SN)
    • Anterior-posterior maxillary deficiency/excess measurement (mm)
    • Any anterior open bite or other vertical anomalies
  3. Occlusal Assessment - Overjet, overbite, posterior bite relationship, midline
  4. Imaging - Lateral cephalometric radiographs, panoramic radiographs, CT scan if asymmetry
  5. Baseline Photographs - Frontal, lateral, oblique, intraoral
  6. Physical Examination - Facial proportions, soft tissue contour, airway assessment (if OSA)
  7. Surgical Technique - LeFort I osteotomy described with specifics
  8. Bone Cuts - Horizontal osteotomy location (above apices), vertical cuts location (lateral maxillary walls), pterygoid plate separation
  9. Maxillary Mobilization - Confirmed mobile as single unit
  10. Repositioning Data:
    • Direction and amount (mm forward/back, rotation degrees, vertical adjustment mm)
    • Bilateral symmetry achieved
    • Intermax fixation or wafers used to guide position
  11. Fixation - CRITICAL:
    • Type (titanium L-plates, hybrid plates, etc.)
    • Number of plates (typically 4-6)
    • Number and locations of screws (typically 24-40+ total)
    • Bilateral confirmation of stability
  12. Soft Tissue Management - Maxillary tuberosity repositioning, nasal base positioning, incision closure
  13. Intraoperative Monitoring - Nerve function (infraorbital, mental nerve), occlusal relationship verification
  14. Intraoperative Complications - None vs. specific issues (bleeding, nerve injury, inadequate mobilization, asymmetry requiring correction)
  15. Operative Time - Total time in OR
  16. Estimated Blood Loss - Important for post-op management, transfusion decisions
  17. Post-Operative Instructions - Dietary restrictions, activity limits, medications, followup schedule
  18. Post-Operative Notes (Global Period) - Wound healing, maxillary position assessment, occlusal verification, neurosensory status, hardware stability

✗ SHOULD AVOID:

  • Vague descriptions (“LeFort I performed” without specifics on direction, amount, fixation)
  • Missing cephalometric measurements (no SNA, SNB, ANB angles)
  • Incomplete bone cut description (which cuts? which areas?)
  • No documentation of maxillary positioning (how much movement? in which direction?)
  • No fixation details (plates? screws? bilateral?)
  • Copy-paste documentation without case-specific details
  • Missing baseline photography
  • No mention of post-operative position assessment (final occlusion, midline, symmetry)

Sample Operative Note Template

OPERATIVE REPORT - LeFort I Maxillary Osteotomy (21315)

PATIENT: [Name], Age [X]
DATE OF PROCEDURE: [Date]
SURGEON: [Name, Credentials]
ANESTHESIA: General endotracheal anesthesia; nasotracheal intubation for intraoral approach

INDICATION:
Patient is a [X]-year-old with [Class II/III malocclusion / maxillary hypoplasia / anterior open bite / asymmetry] with documented functional impairment [eating difficulty / speech / sleep apnea]. Cephalometric analysis shows [specific measurements: SNA [X]° (deficient/excessive), SNB [X]°, ANB [X]°, anterior-posterior maxillary deficiency [X]mm]. Orthodontic correction completed. Patient is surgical candidate for orthognathic correction.

PRE-OPERATIVE FINDINGS:

  • Lateral cephalometric radiographs:
    • SNA angle: [X]° (normal 82°)
    • SNB angle: [X]° (normal 80°)
    • ANB angle: [X]° (normal 2° for Class I)
    • Vertical dimensions: [GOAOR X]°, [MP to SN X]°
    • Anterior-posterior maxillary deficiency: [X]mm
    • [Other findings as relevant]
  • Panoramic radiographs: [Findings; bone height, dental status, symmetry]
  • CT scan: [If obtained; specific findings regarding asymmetry, bone anatomy]
  • Clinical exam: [Overjet X mm, overbite X mm, posterior bite Class X, midline deviation X mm]
  • Occlusal assessment: [Specific findings]
  • Baseline photographs: Frontal, lateral, oblique, intraoral views obtained

SURGICAL TECHNIQUE:

Patient positioned supine, prepped and draped in sterile fashion. General anesthesia induced. Nasotracheal tube placed to allow intraoral access.

Incisions and Exposure: Intraoral incision made in vestibule above teeth from molar region bilaterally across midline. Full-thickness flap elevated to expose maxillary sidewalls, zygomaticmaxillary junction, and anterior maxilla.

Bone Cuts:

  • Horizontal osteotomy: Cut made above the apices of maxillary teeth using [oscillating saw / rotary saw], extending from pterygoid plates posteriorly through anterior maxilla. Cut positioned [X]mm above apical roots to preserve tooth vitality.
  • Vertical cuts: Made on lateral maxillary walls between maxilla and zygoma bilaterally, extending from horizontal osteotomy superiorly to pterygomaxillary junction.
  • Pterygoid plates: Released posteriorly with osteotome to allow maxillary mobility.

Mobilization: Maxilla gently mobilized with [osteotome / lever / spreader]. Complete separation confirmed with gentle manipulation. Maxilla confirmed mobile as single unit.

Repositioning: Maxilla repositioned [forward X mm / backward X mm] in anterior-posterior direction. Vertical [raised / lowered] [X]mm. Rotation applied to correct cant: [X] degrees. Final position verified to match surgical plan and achieve desired occlusion.

Fixation: Rigid internal fixation applied using titanium [L-plates / hybrid plates]:

  • Bilateral plates placed at [locations: e.g., pyriform aperture, zygomaticmaxillary junction, posterior maxilla]
  • [Total: typically 4-6 plates with multiple 2.0mm screws each]
  • Plates secured with 2.0mm titanium screws; typically 24-40+ total screws
  • Bilateral symmetry and stability confirmed with manipulation
  • Intermax fixation [used / not used] to guide final occlusion

Soft Tissue Management: Maxillary tuberosity repositioned as needed with maxillary advancement. Nasal base repositioned. Soft palate assessed for integrity. Incisions irrigated with [antibiotic solution].

Closure: Intraoral incisions closed in layers using [resorbable sutures / other materials] using [technique].

Intraoperative Findings:

  • Infraorbital nerve visualized and preserved
  • Mental nerve function maintained
  • Occlusal relationship final assessment: [Specific measurements: overjet X mm, overbite X mm, midline aligned, Class I posterior relationship]
  • Bilateral symmetry achieved

Complications: [None / specific complication with management]

Operative Time: [X] hours
Estimated Blood Loss: [X] mL
Transfusion: [Yes/No; if yes, specify units and type]

POST-OPERATIVE PLAN:

  1. Soft diet for 4-6 weeks; avoid hard/crunchy foods.
  2. Jaw elastics [if applicable]: [type] worn for [duration].
  3. Activity restriction: No contact sports or vigorous activity × 6 weeks.
  4. Pain management: [Specific medications and dosing].
  5. Antibiotics: [Type and duration].
  6. Postoperative follow-up appointments: [Schedule dates].
  7. Post-operative radiographs: Lateral cephalometric radiographs scheduled [X] weeks post-op to assess healing and final position.
  8. Expected outcomes: Improved occlusion, profile balance, functional improvement. Full healing expected at 3-6 months; complete bony consolidation at 6-12 months.

AUDIT DEFENSE CHECKLIST FOR 21315

Before billing 21315, verify:

  • Medical necessity documented - Functional impairment (eating, speech, breathing, sleep apnea) or significant skeletal deformity; not purely esthetic
  • Cephalometric analysis documented - SNA, SNB, ANB angles with specific values and interpretation
  • Maxillary deficiency/excess quantified - Specific measurement (mm) from normal values
  • Pre-operative photographs obtained - Frontal, lateral, oblique views as baseline
  • Imaging documented - Lateral cephalometric radiographs, panoramic radiographs
  • Occlusal assessment documented - Overjet, overbite, posterior bite, midline
  • Surgical technique clearly described - LeFort I osteotomy with specific bone cuts and locations
  • Bone cuts documented - Horizontal above apices, vertical on lateral walls, pterygoid separation
  • Maxillary mobilization confirmed - Mobile as single unit before repositioning
  • Repositioning documented - Direction (mm forward/back, rotation degrees, vertical adjustment)
  • Fixation documented - Type (plates), number, location, bilateral confirmation
  • Intraoperative complications documented - Or note “none”
  • Operative time documented - Total time in OR
  • Estimated blood loss documented - Important for post-op planning
  • Post-operative position verified - Final occlusion, midline, symmetry documented
  • No separate billing during global period - Only 21315 (and concurrent mandibular surgery if performed) billable for related care during 90 days
  • Proper modifiers used - -24 if unrelated E/M during global, concurrent procedures billed with both RVU values
  • Diagnosis code supports indication - ICD-10 shows functional/medical necessity, not just esthetic intent
  • Orthodontic coordination - If pre-operative orthodontics, note completion before surgery

RED FLAGS FOR AUDITORS

21315 claims are at audit risk if:

  • ❌ Indication appears purely esthetic (no functional impairment documented)
  • ❌ Cephalometric analysis missing or incomplete (no SNA/SNB/ANB angles)
  • ❌ Surgical technique vague (bone cuts, fixation details not specified)
  • ❌ Fixation details incomplete (plates? screws? number? bilateral?)
  • ❌ Repositioning direction/amount not documented
  • ❌ Maxillary mobilization not confirmed
  • ❌ Post-operative position not documented (final occlusion, midline, symmetry)
  • ❌ Documentation copy-pasted without procedure-specific details
  • ❌ Diagnosis code unrelated to procedure
  • ❌ No baseline photography (may suggest inadequate planning)
  • ❌ Concurrent mandibular surgery billed but mandibular findings/technique not documented
  • ❌ Orthognathic procedures billed without evidence of pre-operative orthodontics
  • ❌ Sleep apnea indication but no sleep study documented
  • ❌ Asymmetry claimed but no CT scan or imaging for asymmetry assessment

MEDICARE RULES & RESTRICTIONS

Who Can Bill 21315?

Qualified Providers:

  • DDS/DMD: Oral and maxillofacial surgeon (board certified or specialty trained preferred)
  • MD: Plastic surgeon, otolaryngologist with maxillofacial surgery training
  • DO: Same specialties as MD

Credentialing Requirements:

  • License to practice dentistry (DDS/DMD) or medicine (MD/DO)
  • Active provider number with Medicare
  • Surgical privileges at hospital or ASC
  • Specialty training in oral/maxillofacial or plastic surgery
  • Board certification strongly preferred by many payers

RHC/FQHC Restrictions

If provider is employed by RHC or FQHC:

  • 21315 is NOT typically performed in RHC/FQHC settings (requires surgical OR)
  • If billed by facility, payment goes to facility’s all-inclusive rate
  • Individual provider cannot bill separately

Assistant at Surgery & Co-Surgery

Assistant at Surgery (Modifier -80, -81, -82):

  • Assistant can be billed separately using appropriate modifier
  • Typical payment: 16-20% of primary surgeon fee
  • Example: If 21315 pays 63 - $79

COMPLIANCE & CODING EXAMPLES

Appropriate 21315 Use Cases ✓

  1. Maxillary hypoplasia with Class II malocclusion - Underdeveloped upper jaw with functional eating difficulty
  2. Anterior open bite - Teeth don’t meet anteriorly; functional and esthetic concern
  3. Sleep apnea - Documented OSA; maxillary advancement to expand airway
  4. Maxillary asymmetry - Documented with imaging; functional asymmetry
  5. Cleft palate sequelae - Maxillary deformity requiring surgical correction after cleft repair
  6. Combined orthognathic surgery - LeFort I + mandibular surgery for bimaxillary correction
  7. Midface deficiency - Underprojected maxilla with functional impairment

Inappropriate 21315 Use (Risks) ✗

  1. ❌ Purely esthetic surgery - No functional impairment documented; only esthetic desires
  2. ❌ No cephalometric analysis - Surgery billed without objective measurements (SNA, SNB, ANB)
  3. ❌ Missing baseline photography - No documentation of pre-operative appearance
  4. ❌ Post-operative E/M billed during global period - Separate E/M coded for related post-op care during 90-day global
  5. ❌ Inadequate surgical documentation - Vague operative notes without bone cut details, fixation specifics
  6. ❌ Concurrent mandibular surgery not documented - If 21315 + 21436 billed, mandibular findings/technique must be documented
  7. ❌ No evidence of pre-operative orthodontics - Teeth should be orthodontically aligned before surgery

FREQUENTLY ASKED QUESTIONS (FAQs)

Q: Can I bill 21315 for purely esthetic surgery?
A: No. Medicare requires functional or medical necessity indication (sleep apnea, eating difficulty, speech impairment, significant asymmetry). Purely esthetic cases not covered. Verify your payer’s policy.

Q: What’s the most common procedure combined with 21315?
A: CPT 21436 (bilateral sagittal split osteotomy, mandible). Bimaxillary surgery (21315 + 21436) is standard for comprehensive orthognathic correction.

Q: Can I bill both 21315 and 21436 same day?
A: Yes. These are distinct procedures performed in same operative session. Both codes billed separately with both RVU values. Both covered by same anesthesia.

Q: What cephalometric measurements do I need to document?
A: Minimum: SNA angle, SNB angle, ANB angle, and anterior-posterior maxillary position (mm from normal). Vertical dimensions recommended. These objective measures support medical necessity.

Q: Is bone graft material included in 21315?
A: Yes. Surgical hardware (plates, screws) and fixation materials are included in 21315 RVU. Do NOT bill separately.

Q: What if I need to revise the LeFort I during the 90-day global period?
A: Revision during global period may be billed as 21315-76 (repeat procedure) or 21315-79 (unrelated procedure during post-op). Verify payer policy; many may deny revision or pay reduced fee. Pre-authorization strongly recommended.

Q: Do I need pre-authorization for 21315?
A: Yes, most payers require pre-authorization for orthognathic procedures. Verify your MAC’s LCD and submit pre-auth with cephalometric analysis, photos, medical necessity documentation.

Q: Can orthodontist bill for pre-operative or post-operative orthodontics?
A: Yes. Orthodontist bills separately for orthodontic services. Surgical team (OMFS) bills for 21315. Both services billed separately.

Q: What if maxillary advancement is only on one side (asymmetry)?
A: Still use 21315 (not side-specific). Asymmetric repositioning is part of LeFort I technique. Document asymmetric measurements and rotation in operative note.

REAL-WORLD BILLING TIPS

Tips to Maximize Compliance & Revenue

  1. Obtain pre-authorization - REQUIRED for orthognathic procedures; submit cephalometric analysis, photos, medical necessity documentation
  2. Document cephalometric measurements - SNA, SNB, ANB angles with specific values (not just “abnormal”)
  3. Obtain baseline photography - Frontal, lateral, oblique; standard of care
  4. Include CT scan for asymmetry - If asymmetry claimed, CT imaging strengthens documentation
  5. Quantify functional impairment - Eating difficulty, speech issues, sleep apnea; specific documentation required
  6. Document bone cuts specifically - Horizontal location (mm above apices), vertical locations (lateral walls), pterygoid separation
  7. Include fixation details - Type of plates, number of plates, screw count and locations
  8. Document post-operative position - Final occlusion, midline alignment, symmetry assessment
  9. Keep operative reports detailed - Pre-operative measurements, surgical technique, fixation specifics, post-operative verification all critical
  10. Coordinate with orthodontist - If concurrent orthodontics, clarify scope (surgical team handles 21315; orthodontist handles orthodontic services)
  11. Bill concurrent mandibular surgery separately - If 21315 + 21436, bill both with both RVU values
  12. Use -24 for unrelated post-op E/M - Separate unrelated problems during 90-day global with -24 modifier

BILLING & CODING RESOURCES

Recommended Resources:

SUMMARY TABLE

ElementDetails
Official DefinitionOsteotomy, maxilla, with synchronous repositioning of segments and soft tissues (LeFort I)
Global Period090 days (major surgical procedure)
Work RVU (2025)7.46
Total RVU (2025, Non-Facility)12.17
Medicare Payment (2025, Non-Facility)~$394
Medicare Payment (2025, Facility)~$351
Typical Time2-3 hours
Provider RequiredOMFS, plastic surgeon with maxillofacial surgery training
Common Modifiers-24 (unrelated post-op E/M), none (routine), -80/-81/-82 (assistant at surgery)
Typical UseMaxillary advancement, Class II correction, sleep apnea, asymmetry
Most Common Pairing21315 + 21436 (bimaxillary surgery)
Common MistakesMissing medical necessity; inadequate cephalometric documentation; vague surgical technique; no baseline photos; concurrent mandibular surgery not documented
Audit RiskModerate-High (medical necessity and documentation critical; pre-auth recommended)
BundlingIncludes surgical hardware; do NOT bill separately
Pre-AuthorizationSTRONGLY RECOMMENDED; most payers require pre-auth
Telehealth AllowedNo (major surgical procedure requires in-person)

Document Created: February 2026
Compliant with: 2025 Medicare Physician Fee Schedule, CMS National and Local Coverage Determinations, AAOMS Coding Guidelines
Last Updated: February 2026

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