👩🏾‍⚕️CPT Code 21315: Documentation & Billing Guide

Osteotomy, Maxilla, LeFort I; Single Piece or in Combination

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

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Element	Details
Code	21315
Code Type	Surgical Procedure - Maxillofacial Surgery
Procedure Type	LeFort I Osteotomy (maxillary surgery)
Global Period	090 days (major surgical procedure)
Work RVU (2025)	8.30 RVU
Practice Expense RVU (2025, Non-Facility)	4.78 RVU
Practice Expense RVU (2025, Facility)	3.25 RVU
Malpractice RVU (2025)	1.00 RVU
Total RVU (2025, Non-Facility)	14.08 RVU
Total RVU (2025, Facility)	12.55 RVU
2025 Medicare Fee (Non-Facility)	~ $455.24 (14.08 R V U \times$ 32.3465 CF × GPCI)
2025 Medicare Fee (Facility)	~ $405.91 (12.55 R V U \times$ 32.3465 CF × GPCI)
Conversion Factor (2025)	$32.3465
Estimated Commercial Insurance	$1,200 - 2,000
Global Period Includes	Pre-operative visits, surgery, post-operative visits (90 days)
Common Place of Service	Hospital inpatient (21), Hospital outpatient (22), ASC (24)
Specialty	Oral & Maxillofacial Surgery, Otolaryngology, Plastic Surgery
Bilateral Status	Unilateral code; use -RT/-LT for side-specific or -50 for bilateral

📋SHORT DEFINITION

CPT 21315 describes a LeFort I maxillary osteotomy, a surgical procedure in which the maxilla (upper jaw) is surgically fractured and repositioned to correct severe malocclusion, facial asymmetry, or other maxillofacial deformities. The procedure can be performed as a single-piece movement or with additional segments or combinations as needed.

LONG DEFINITION

CPT 21315 represents a LeFort I maxillary osteotomy with or without bone graft(s). This is a major orthognathic (jaw alignment) surgical procedure that involves:

Surgical fracturing of the maxilla at a horizontal level above the apices of the teeth through an intraoral approach
Downward fracture through the nasal septum and pterygoid plates to mobilize the entire maxilla
Repositioning of the maxilla forward, backward, up, or down depending on the desired correction
Fixation of the maxilla in the new position using plates, screws, or other internal fixation devices
Possible bone graft placement to fill gaps or augment bone (included in 21315 code)

Procedure Description:

Intraoral incision made along the gingival margin (gum line)
Soft tissue reflected to expose the anterior maxilla
Horizontal bone cuts made bilaterally through the maxillary sinuses
Nasal septum separated from the maxilla
Pterygoid plates disarticulated posteriorly to allow full downward fracture and mobilization
Maxilla moved to correct the malocclusion (bite relationship)
Internal fixation applied (rigid fixation with plates and screws)
Incisions closed

Common Clinical Indications:

Severe anterior open bite (inability to close teeth in front)
Severe overbite or underbite unresponsive to orthodontics
Maxillary hypoplasia (underdeveloped upper jaw)
Maxillary hyperplasia (overdeveloped upper jaw)
Severe maxillary asymmetry
Sleep apnea correction (advancing maxilla for airway expansion)
Dentofacial deformity with significant functional or esthetic impairment
Correction after maxillary trauma or congenital malformation

Procedure Duration: Typically 2-4 hours depending on complexity

Key Distinctions:

CPT 21315 = LeFort I (horizontal osteotomy above tooth apices)
CPT 21316 = LeFort I with bone graft (same as 21315 but specifically notes graft; many insurers bundle these)
CPT 21320 = LeFort II (pyramid-shaped fracture, more complex)
CPT 21330 = LeFort III (complete midface-cranial base separation, most complex)
CPT 21346-21348 = Other maxillary osteotomies (sagittal split, vertical, etc.)

Important Note: CPT 21315 includes bone graft if used (e.g., autologous bone, allograft, bone morphogenetic protein). Do NOT bill separately for graft material when using 21315.

WORK RELATIVE VALUE UNITS (wRVUs) & COMPONENTS

Work RVU Breakdown (2025)

RVU Component	Value	What It Represents
Work RVU	8.30	Physician work, technical skill, time, decision-making
Practice Expense RVU (non-facility)	4.78	Surgical instruments, facility overhead, staff support
Practice Expense RVU (facility)	3.25	Lower due to hospital/ASC equipment overhead
Malpractice RVU	1.00	Malpractice insurance and liability (major surgery)
TOTAL RVU (non-facility)	14.08	Total relative value units
TOTAL RVU (facility)	12.55	Total 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):

8.30 wRVU × $32.3465 = * *$ 268.68** (work component)
4.78 PE RVU × $32.3465 = * *$ 154.50** (practice expense)
1.00 MP RVU × $32.3465 = * *$ 32.35** (malpractice)
Total = ~$455.24 per procedure (non-facility, GPCI 1.0)

Facility-Based (Hospital/ASC):

8.30 wRVU × $32.3465 = * *$ 268.68** (work component, same)
3.25 PE RVU × $32.3465 = * *$ 105.13** (practice expense, lower)
1.00 MP RVU × $32.3465 = * *$ 32.35** (malpractice, same)
Total = ~$405.91 per procedure (facility, GPCI 1.0)

Real-World Range (2025):

Non-Facility (Office-based OR): $420 -$ 530 (depending on GPCI, location adjustments)
Facility-Based (Hospital OR, ASC): $375 -$ 475 (lower PE RVU, facility overhead covered)

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
- The surgery itself
- All post-operative visits within 90 days (routine follow-up, wound checks, etc.)
- Hospital care related to the procedure
- Post-operative complications related to the surgery (unless separately billable)
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 (e.g., post-op check) - 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 with modifier -59 (distinct procedural service)
Global period does NOT include costs for hospitalization; hospital bills separately for facility/room charges

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 - Lefort 1 Guide 2

Minimum Documentation Components

Pre-Operative Assessment & Workup:

Chief Complaint/Indication: Malocclusion, facial asymmetry, functional/esthetic impairment, sleep apnea
History: Duration of dental problem, prior orthodontics, failed conservative treatment
Physical Examination: Occlusal relationship (overjet, overbite, open bite), facial asymmetry, nasal patency
Imaging: Cephalometric radiographs, panoramic films, CT scan findings if available
Orthodontic records: Pre-operative photos, X-rays, study models
Informed consent: Documentation of risks, benefits, alternatives discussed with patient

Surgical Procedure Documentation:

Approach: Intraoral approach, downward fracture technique
Extent of fractures: Bilateral horizontal osteotomy through maxillary sinuses, nasal septum separation, pterygoid plate separation
Bone cuts: Extent and location documented
Mobilization: Complete downward fracture of maxilla confirmed
Repositioning: Direction and amount of movement (mm forward, backward, up, down)
Fixation: Type of fixation (plates, screws, number and location)
Bone graft (if used): Type of graft (autologous, allograft), location, amount
Soft tissue repair: Closure technique, layers
Complications: Intraoperative bleeding, mucosal tears, nerve involvement, etc.
Estimated blood loss: Important for postoperative management
Operative time: Total time in OR

Post-Operative Plan:

Occlusion: Final tooth contact confirmed or rubber band elastics for guidance
Dietary modifications: Soft diet instructions
Activity restrictions: When patient can return to normal activity
Medications: Pain management, antibiotics, other medications
Follow-up: Post-op visit schedule (typically day 1-2, week 1, week 3, 6 weeks, 3 months, 6 months)
Orthodontic follow-up: With orthodontist for final alignment

Post-Operative Notes (Included in Global Period):

Wound status: Healing, swelling, ecchymosis (bruising)
Occlusion: Occlusal relationship, any elastics adjusted
Infection/complications: None vs. specific issues
Pain management: How well controlled
Activity tolerance: Progressive return to normal activity

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
The surgical procedure itself
All post-operative office visits for related care
Hospital/facility charges (though hospital bills separately for facility)
Routine post-operative complications management
Removal of sutures
Wound checks
Post-operative radiographs related to the surgery

✗ 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)
Services outside the scope of the surgical package

Modifiers for Global Period

Modifier	Description	When to Use
-24	Unrelated E/M during postoperative period	When billing E/M for unrelated problem during 90-day period
-59	Distinct procedural service	When performing unrelated procedure same day
-RT/-LT	Right/Left side	For side-specific variations of 21315
-50	Bilateral procedure	If bilateral LeFort I performed (uncommon but possible)
-LT/-RT	Side-specific	To indicate right or left side of maxilla
None (most common)	Standard billing	Routine unilateral LeFort I

Modifier -24 Usage (Unrelated E/M During Global):

When: Patient returns during 90-day post-op period for unrelated problem (e.g., hypertension check, other illness)
Apply -24 to: The E/M code, not the 21315
Example: Patient 2 weeks post-LeFort I returns for unrelated sore throat → Bill 99213-24 for throat problem (separate from global package)

Modifier -59 Usage (Distinct Procedure Same Day):

When: Additional unrelated procedure performed same day as 21315
Apply -59 to: The additional procedure code
Example: 21315 + mandibular osteotomy (21447) with -59 on 21447 (if distinctly separate procedures)

MEDICARE RULES FOR 21315

CMS-Specific Rules & Policies

1. Global Period Management (Critical)

90-day global period is standard
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 (4.78), higher reimbursement (~$455)
Facility (hospital OR, ASC): Lower PE RVU (3.25), lower reimbursement (~$406)
Facility also bills separately for facility charges (hospital or ASC facility fee)

3. Bilateral Considerations

LeFort I typically unilateral (standard code 21315)
If bilateral LeFort procedures performed, bill 21315 + 21315-50 or 21315-LT + 21315-RT (verify payer policy)
Most payers pay 150% for bilateral procedures (100% + 50% of second side)

4. Assistant at Surgery

Can bill assistant surgeon (modifier -80 or -81 or -82, depending on provider type)
Assistant typically paid 16-20% of primary surgeon fee
Verify Medicare rules for specific assistant modifiers in your region

5. Bone Graft Inclusion

Bone graft material and placement included in 21315 code
DO NOT bill separately for graft material (CPT 20930-20938) when using 21315
If graft harvested from separate site with significant additional work, some payers allow separate billing with -59 modifier (verify policy)

6. Local Coverage Determinations (LCDs)

Check your MAC jurisdiction for specific coverage requirements
Some MACs require pre-authorization for orthognathic surgery
Documentation must show medical necessity (functional impairment, not just esthetic)

LOCAL COVERAGE DETERMINATIONS (LCDs) & NATIONAL COVERAGE

National Coverage Determination (NCD)

There is NO specific NCD for CPT 21315.

General Medicare Coverage Policy:

LeFort I osteotomy covered when performed for documented medical necessity (functional impairment, not purely esthetic)
Requires demonstration of:
- Documented severe malocclusion (orthodontically unresponsive)
- Functional impairment (difficulty chewing, speaking, breathing, or sleep apnea)
- Failed conservative treatment (orthodontics alone insufficient)
- Surgical intervention medically appropriate to correct underlying condition

Local Coverage Determinations (LCDs) - MAC-Specific

LCDs vary by Medicare Administrative Contractor (MAC) jurisdiction.

Common LCD Requirements for 21315:

Requirement	Details
Medical Necessity	Documentation showing functional impairment or sleep apnea; not purely esthetic
Failed Conservative Treatment	Orthodontics attempted and failed to correct malocclusion
Severity Documentation	Objective measurements (ANB angle, overjet, overbite) showing significant deformity
Imaging	Cephalometric radiographs and panoramic films required
Pre-Authorization	Many MACs require prior authorization before surgery
Surgeon Credentials	Board certification in oral/maxillofacial surgery or specialty training required
Bone Graft Policy	Graft typically included; clarify if additional graft harvesting separately billable

To Find Your MAC’s LCD:

Go to CMS LCD Search Tool: https://www.cms.gov/cclc/lcd
Enter your MAC jurisdiction
Search for “LeFort osteotomy,” “maxillary osteotomy,” or “orthognathic surgery”
Review coverage criteria and prior 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 1/15/2026 (90-day global ends 4/15/2026)
On 2/1/2026, patient returns for unrelated hypertension management
Coding: 99213 -24 for hypertension (unrelated to LeFort I)
The 21315 global fee is NOT reduced; separate E/M payment applies

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

Modifier -59 (Distinct Procedural Service)

Use when: Performing distinct, unrelated procedure same day as 21315

Example:

Patient undergoing LeFort I + blepharoplasty (eyelid surgery) same day
These are distinct procedures
Coding: 21315 + blepharoplasty code (e.g., 15820-59)
Both procedures billed, both paid (if criteria met)

Modifier -50 (Bilateral Procedure)

Use when: Bilateral LeFort procedures performed simultaneously

Billing:

21315-50 (bilateral modifier, fewer insurers accept)
OR 21315-LT + 21315-RT (side-specific modifiers, more common)
OR 21315 + 21315-50 (first code without modifier, second with -50)

Payment: Typically 150% of base code (100% + 50%)

2025 REIMBURSEMENT INFORMATION

Medicare 2025 Fee Schedule

CPT 21315 - LeFort I Maxillary Osteotomy

Category	Value
Work RVU	8.30
Practice Expense RVU (non-facility)	4.78
Practice Expense RVU (facility)	3.25
Malpractice RVU	1.00
Total RVU (non-facility)	14.08
Total RVU (facility)	12.55
Conversion Factor (2025)	$32.3465
National Average Fee (Non-Facility, GPCI 1.0)	$455.24
Estimated Range (Non-Facility)	$420 - 530
National Average Fee (Facility, GPCI 1.0)	$405.91
Estimated Range (Facility)	$375 - 475

Year-Over-Year Comparison (2024 vs 2025)

Metric	2024	2025	Change
Work RVU	8.30	8.30	—
PE RVU (non-facility)	4.78	4.78	—
CF	$33.2875	$32.3465	-2.8%
National Average (Non-Facility)	~$468.69	~$455.24	-2.8%
Global Period	090	090	—

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: $1, 200 -$ 2,000 (varies widely by payer)
Often requires pre-authorization
Some payers may require evidence of orthodontic treatment failure

Medicaid:

Varies significantly by state
Estimated 21315 payment: $400 -$ 900 (state-dependent)
Many states cover orthognathic surgery for functional impairment
Some states don’t cover (considered esthetic in their policies)
Prior authorization typically required

Self-Pay/Cash Price:

Typically $3, 000 -$ 8,000 depending on provider, location, complexity
Often offered with financing plans

Maxillary Osteotomy Code Family

Code	Description	Complexity	RVU (Work)	Global
21315	LeFort I, single piece or combination	Moderate	8.30	090
21316	LeFort I with bone graft	Moderate	8.30	090
21320	LeFort II (pyramid fracture)	High	10.60	090
21330	LeFort III (midface-cranial separation)	Very High	13.60	090
21346	Maxilla osteotomy, sagittal split	Moderate	8.80	090
21347	Maxilla osteotomy, vertical	Moderate	8.80	090
21348	Maxilla osteotomy, other	Moderate	8.80	090

21315 vs 21316 (Graft Designation)

Aspect	21315	21316
Procedure	LeFort I osteotomy	LeFort I with bone graft
RVU (Work)	8.30	8.30
Graft Included	Usually yes (standard code)	Yes (explicit in description)
Graft from Own Bone	Included	Included
Allograft	Included	Included
When to Use 21316	Older guidelines or specific payer policy	When graft explicitly documented and payer requires separate code

Clinical Note: Most modern practices bill 21315 routinely. Many insurers have bundled 21315 and 21316 to the same code (21315). Verify your payer’s policy on graft coding.

FREQUENTLY BILLED SCENARIOS FOR 21315

Scenario 1: LeFort I for Anterior Open Bite

Patient: 24-year-old with severe anterior open bite (inability to close teeth in front)
Pre-Operative Assessment: Cephalometric radiographs show vertical maxillary excess, ANB angle 10°, anterior open bite 8mm
Orthodontics: 18 months of orthodontic treatment completed; open bite persists despite comprehensive treatment
Surgical Plan: LeFort I maxillary impaction (move maxilla up) to close bite and correct vertical excess
Procedure: LeFort I osteotomy performed. Maxilla impacted 6mm vertically and advanced 3mm anteriorly. Bilateral sagittal split mandibular osteotomy (CPT 21447) performed simultaneously for combined correction. Rigid internal fixation with titanium plates. Postoperative elastics applied.
Coding:

21315 (LeFort I maxillary osteotomy)
21447 (Mandibular osteotomy, sagittal split, unilateral) or 21448 (bilateral)
Both codes billed for single anesthetic session; both payable (distinct procedures)
Diagnosis: M26.220 (anterior open bite), M26.24 (excessive vertical dimension)

Scenario 2: LeFort I for Maxillary Hypoplasia with Underbite

Patient: 28-year-old with cleft palate history, severe underbite, maxillary retrusion
Pre-Operative Assessment: Class III malocclusion with maxilla set back relative to mandible. Cleft repair performed in childhood; surgical sites healed.
Surgical Plan: LeFort I maxillary advancement to correct underbite
Procedure: LeFort I osteotomy performed. Maxilla advanced 9mm anteriorly and rotated to correct bite relationship. Autologous bone graft harvested from iliac crest and placed into gaps created by osteotomy. Rigid internal fixation with titanium plates bilaterally.
Post-Op: Elastics applied for 4 weeks, then transitioned to normal occlusion.
Coding:

21315 (LeFort I with bone graft—included in code)
Diagnosis: M26.81 (anterior relation anomaly), Q35.9 (cleft palate, history)
Do NOT bill separately for bone graft (included in 21315)

Scenario 3: LeFort I During Global Period (Unrelated E/M)

Scenario: Patient is in post-op period from LeFort I (surgery 2/1/2026, global period 2/1-5/1/2026). On 2/15/2026, patient develops upper respiratory infection and returns for evaluation and treatment.
E/M Assessment: Fever, cough, nasal congestion; not related to LeFort I surgery
Diagnosis: Acute upper respiratory infection
Coding:

99213-24 (E/M for unrelated URI; modifier -24 indicates unrelated post-op service)
Do NOT include this visit in 21315 global period
Separate payment for 99213-24 in addition to global payment for 21315

Scenario 4: Bilateral LeFort I (Uncommon)

Scenario: Patient undergoing simultaneous bilateral maxillary advancement surgery (rare but possible in extreme asymmetry cases)
Procedure: LeFort I technique applied to both sides of maxilla with advancement, rotation, and fixation
Coding (Verify payer policy):

Option 1: 21315-50 (bilateral modifier—150% payment: 100% + 50%)
Option 2: 21315-LT + 21315-RT (side-specific—150% payment)
Option 3: 21315 + 21315 (separate line items—150% payment)
Most payers: Pay 150% of base code for true bilateral procedures

DOCUMENTATION TIPS FOR 21315

What to Document

✓ SHOULD INCLUDE:

Indication for Surgery - Malocclusion type, functional impairment (eating, speaking, breathing, sleep)
Failed Conservative Treatment - Orthodontics attempted and duration; reasons inadequate
Severity Measurements:
- Overjet (horizontal overlap of front teeth)
- Overbite (vertical overlap)
- Open bite distance (if anterior open bite)
- ANB angle from cephalometrics
Imaging Results - Cephalometric analysis, CT scan findings, panoramic radiographs
Pre-Operative Photos - Frontal, profile, intraoral views (optional but helpful)
Physical Examination - Occlusal assessment, facial symmetry, nasal patency
Surgical Technique:
- Intraoral approach documented
- Extent of osteotomy (horizontal cuts, pterygoid separation)
- Mobilization of maxilla confirmed
Repositioning Data:
- Direction of movement (forward, backward, up, down)
- Amount of movement in millimeters
- Final occlusal relationship achieved
Fixation Method - Type (plates, screws), number, location bilaterally
Bone Graft (if used):
- Type (autologous, allograft, other)
- Source (if autologous)
- Location placed in maxilla
- Amount used
Intraoperative Complications - Bleeding control, mucosal tears, nerve visualization
Estimated Blood Loss - Important for post-op management
Operative Time - Total time in OR
Post-Operative Instructions:
- Dietary modifications
- Activity restrictions
- Medication list
- When to call with concerns
Follow-Up Schedule - Specific dates for post-op visits

✗ SHOULD AVOID:

Vague descriptions (“osteotomy performed” without specifics)
Incomplete positioning documentation (which direction, how much?)
Missing imaging/pre-operative findings
No documentation of orthodontic failure/conservative treatment
Copy-paste from previous procedures without updating
Incomplete assessment of functional impairment

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

INDICATION:
Patient is a [X]-year-old with severe [anterior open bite / Class III malocclusion / maxillary hypoplasia] unresponsive to [X] months of orthodontic treatment. Cephalometric analysis shows [specific measurements: ANB angle X°, anterior open bite X mm, maxillary retrusion X mm]. Surgical correction recommended to restore normal occlusion and function.

PRE-OPERATIVE FINDINGS:

Cephalometric analysis: [specific measurements]
Panoramic radiographs: Normal dentition, good bone quality
CT scan: [if obtained; specific findings]
Physical exam: Anterior open bite [X mm], overjet [X mm], facial asymmetry [if present]
Orthodontics: [Duration], [type of brackets/appliances], [outcome]

SURGICAL TECHNIQUE:

Patient positioned supine, prepped and draped in routine sterile fashion. General anesthesia induced. Endotracheal tube placed.

Approach: Intraoral incision placed along the gingival margin from first molar to first molar bilaterally, extending superiorly to periosteal reflection.

Osteotomy: Bilateral horizontal osteotomy cuts made through the maxillary sinuses at the level of the apices of the maxillary teeth using reciprocating saw. Cut extended medially to the nasal septum and posteriorly to the posterior wall of the maxillary sinus. Pterygoid plates disarticulated posteriorly with osteotome and mallet to complete the downward fracture. Maxilla mobilized and carefully downward-fractured, confirming complete separation from cranial base.

Repositioning: Maxilla repositioned [forward X mm / backward X mm / rotated X degrees / impacted X mm vertically] to achieve Class I molar and canine relationship with anterior overjet [X mm] and overbite [X mm]. Posterior open bite corrected to anterior contact.

Fixation: Rigid internal fixation applied bilaterally using [number] titanium plates (L-plates, hybrid plates, or other type) and [number] screws. Fixation confirmed stable with manipulation. Occlusion verified with patient’s pre-operative occlusal splint or intraoperative registration.

Bone Graft [if used]: [Type of graft—autologous from [source], allograft, or BMP] obtained and placed in osteotomy gaps bilaterally [specify amount and location].

Soft Tissue Closure: Periosteum and mucosa closed in layers with [suture type]. Elastics [applied/not applied] as part of postoperative retention.

Hemostasis: Complete hemostasis achieved. Minimal bleeding controlled with cautery and local hemostatic agents.

Complications: None.

Operative Time: [X] hours
Estimated Blood Loss: [X] mL

POST-OPERATIVE PLAN:

Patient to remain intubated overnight for airway monitoring.
Soft diet, no hard foods for 6 weeks.
Pain management: Narcotic analgesics as needed, then transition to non-narcotic.
Antibiotics: [Type] for [duration].
Postoperative follow-up: [Schedule specific dates and times]
Orthodontist follow-up: After initial healing (typically 4 weeks post-op).

AUDIT DEFENSE CHECKLIST FOR 21315

Before billing 21315, verify:

RED FLAGS FOR AUDITORS

21315 claims are at audit risk if:

❌ Medical necessity documentation missing (appears purely esthetic rather than functional)
❌ Pre-operative testing (cephalometric analysis, imaging) not documented
❌ Orthodontic history missing or incomplete (how long attempted, why inadequate?)
❌ Surgical technique vague or incomplete (which osteotomy cuts, extent of mobilization?)
❌ Repositioning data missing (amount and direction of movement not documented)
❌ Fixation details incomplete (type, location, bilaterally?)
❌ Bone graft billed separately (20930-20938) when 21315 used (graft included in 21315)
❌ Post-operative visits billed as separate E/M during global period (should be included unless unrelated with -24 modifier)
❌ Global period exceeded (surgery on X date, billing post-op visit on date outside 90-day window?)
❌ Bilateral LeFort procedures billed without bilateral modifier or appropriate side-specific modifiers
❌ Documentation copy-pasted from templates without procedure-specific details
❌ Diagnosis code unrelated to procedure (e.g., billing for cosmetic surgery with E/M diagnosis)

MEDICARE RULES & RESTRICTIONS

Who Can Bill 21315?

Qualified Providers:

DDS/DMD: Oral and maxillofacial surgeon (specialty trained and board certified preferred by Medicare)
MD: Otolaryngologist with maxillofacial surgery training, plastic surgeon with craniofacial fellowship
DO: Same specialties as MD

Credentialing Requirements:

Board certification in oral/maxillofacial surgery (or equivalent specialty training)
Active provider number with Medicare
Hospital or ASC surgical privileges
May require specific authorization for orthognathic surgery by some payers

RHC/FQHC Restrictions

If provider is employed by RHC or FQHC:

21315 is NOT typically performed in RHC/FQHC settings (requires OR)
If somehow 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 $455, a ss i s t an t a t s u r g ery (m o d i f i er [[- 80]]) p a ys$ 73 - $91

Co-Surgery (-62):

Two surgeons working simultaneously on same patient
Each surgeon bills 21315-62
Each receives 50% of fee (two 50% payments = 100% coverage of procedure)

COMPLIANCE & CODING EXAMPLES

Appropriate 21315 Use Cases ✓

Severe anterior open bite - Cephalometric evidence of vertical maxillary excess, orthodontically unresponsive
Class III malocclusion - Maxillary hypoplasia, functional eating/speaking impairment
Severe overbite - Excessive horizontal overlap causing esthetic/functional impairment
Sleep apnea - Maxillary hypoplasia contributing to airway obstruction; surgical advancement for airway expansion
Cleft palate sequelae - Maxillary retrusion after cleft repair; orthodontics insufficient for correction
Maxillary asymmetry - Functional and esthetic impairment; conservative treatment failed
Dentofacial trauma sequelae - Maxillary malposition after healing; surgical correction for function/esthetics

Inappropriate 21315 Use (Risks) ✗

❌ Purely esthetic surgery - No documented functional impairment, only esthetic desires
❌ Without failed orthodontic treatment - Surgery billed without evidence of adequate orthodontic trial
❌ Missing cephalometric analysis - Surgery billed without imaging documentation of severity
❌ Bone graft billed separately - Using both 21315 + bone graft codes (20930-20938) when graft included in 21315
❌ Post-operative E/M billed during global period - Separate E/M coded for related post-op care during 90-day global (should be included)
❌ Upcoded from simpler osteotomy - Using 21315 when simpler procedure (21121 genioplasty) would be appropriate

FREQUENTLY ASKED QUESTIONS (FAQs)

Q: Can I bill 21315 for purely esthetic reasons?
A: No. Medicare requires documentation of functional impairment (eating, speaking, breathing, sleep apnea) to establish medical necessity. Purely esthetic cases are not covered.

Q: Should I bill 21315 or 21316 if graft is used?
A: Typically 21315 (standard code). 21316 is older coding convention explicitly noting graft. Many insurers have bundled these codes. Check your payer’s policy; most modern practices use 21315 routinely regardless of graft.

Q: Can I bill the bone graft separately if I harvest from iliac crest?
A: No. Bone graft is included in 21315 RVU. Do NOT bill separately (20930-20938) when using 21315. Some payers allow additional payment for graft HARVESTING from anatomically distant site with -59 modifier, but graft placement is included.

Q: What’s the difference between 21315 and 21316?
A: Minimal. 21315 is the standard code; 21316 explicitly notes bone graft in descriptor. RVU and payment are identical. 21315 used for most cases today.

Q: Can I bill post-operative visit E/M codes during the 90-day global period?
A: NO, for related care. Post-operative visits are included in the global fee. You can only bill separate E/M with modifier -24 if the visit addresses an unrelated problem.

Q: Can I bill 21315 if my patient is mandibular surgery only?
A: No. 21315 is specifically maxillary (upper jaw) osteotomy. For mandibular-only surgery, use 21447 (sagittal split), 21453 (anterior alveolar), or other mandibular codes.

Q: Can I bill 21315 + 21447 (mandibular surgery) same day?
A: Yes. These are distinct procedures (max + mandible), both billable with both RVUs paid. Both included in same anesthesia/operative session. Both carry 90-day global periods (though coincide).

Q: Does 21315 include the orthodontist post-operative care?
A: No. Orthodontist bills separately for post-operative orthodontic management (e.g., final bracket adjustments, elastic changes, monitoring). Orthodontist’s work is not in global period.

Q: What if my LeFort I is only on one side?
A: Still use 21315 (unilateral code). Modifier -LT (left) or -RT (right) can denote side if needed, but payment remains same. True bilateral (both sides simultaneously) would use bilateral modifier.

REAL-WORLD BILLING TIPS

Tips to Maximize Compliance & Revenue

Document medical necessity thoroughly - Functional impairment, orthodontic failure, cephalometric measurements all critical
Obtain pre-authorization - Many payers require pre-auth for orthognathic surgery; reduces claim denials
Use proper imaging - Cephalometric analysis and CT scans document severity; required by most payers
Do NOT bill graft separately - Common error: billing 20930 + 21315 results in denial; graft included
Manage global period correctly - Track 90-day period; don’t code separate E/M during period for related care
Use -24 modifier appropriately - Separate unrelated problems during global period with -24 on E/M
Verify bilateral modifiers - If bilateral LeFort, confirm payer’s preference: -50 vs. -LT/-RT vs. two separate codes
Include operative report details - Specific measurements, repositioning amounts, fixation details all help with audits
Coordinate with orthodontist - Ensure clear handoff of post-operative care; orthodontist handles final alignment
Keep comprehensive documentation - Pre-op photos, cephalometrics, CT scans, operative report, post-op notes all important for defense

BILLING & CODING RESOURCES

Recommended Resources:

AMA CPT Manual 2025 - Official CPT code definitions
CMS Fee Schedule Database: https://www.cms.gov/medicare/physician-fee-schedule
MAC LCDs: https://www.cms.gov/cclc/lcd (search for “orthognathic” or “maxillary osteotomy”)
American Association of Oral and Maxillofacial Surgeons (AAOMS): https://www.aaoms.org (coding resources)
Your payer’s provider manual - Payer-specific coverage requirements and modifiers

SUMMARY TABLE

Element	Details
Official Definition	Osteotomy, maxilla, LeFort I; single piece or in combination
Global Period	090 days (major surgical procedure)
Work RVU (2025)	8.30
Total RVU (2025, Non-Facility)	14.08
Medicare Payment (2025, Non-Facility)	~$455
Medicare Payment (2025, Facility)	~$406
Typical Time	2-4 hours
Provider Required	OMFS, plastic surgeon, ENT (specialty training/board certification)
Common Modifiers	-24 (unrelated post-op E/M), -59 (distinct procedure), -50/-LT/-RT (bilateral/side-specific)
Typical Use	Anterior open bite, Class III malocclusion, maxillary hypoplasia, sleep apnea
Common Mistakes	Missing medical necessity documentation; graft billed separately; global period violations; no orthodontic history
Audit Risk	Moderate-High (medical necessity must be clear; detailed documentation essential)
Bundling	Includes bone graft; do NOT bill separately
Telehealth Allowed	No (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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21315 - Lefort I Guide 1