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21347

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🧬CPT Code 21347: Open Treatment of Nasomaxillary Complex Fracture (LeFort II) with Multiple Surgical Approaches

Overview

CPT code 21347 represents open treatment of a nasomaxillary complex fracture (LeFort II pattern), utilizing multiple surgical approaches with or without internal or external fixation. This code captures one of the most technically demanding procedures in maxillofacial trauma surgery, reserved for cases where the pyramidal midface fracture requires exposure from multiple anatomical vectors to achieve adequate visualization, reduction, and stabilization.

Conceptual Framework

Think of the midface as a architectural bridge system with multiple support pillars. A LeFort II fracture breaks this bridge at its central support points—the nasal bridge, orbital rims, and maxillary buttresses. Repairing it with a single approach would be like trying to fix a collapsed bridge from only one side of the river: you need access from multiple angles to properly realign and stabilize all structural components.

The “multiple approaches” designation distinguishes this from 21346 (single approach) and indicates that the surgeon must create separate surgical access points—typically combining coronal, subciliary, transconjunctival, intraoral, or external facial incisions—to adequately visualize and repair all fracture components.

Clinical Definition & Biomechanics

LeFort II Fracture Pattern

The LeFort II (pyramidal) fracture represents a midface separation involving:

  • Nasal bones and septum (apex of pyramid)
  • Medial orbital walls (ethmoid region)
  • Inferior orbital rims (infraorbital regions bilaterally)
  • Anterior maxillary walls (including infraorbital foramen)
  • Pterygoid plates (posterior attachments)

Mechanism of Injury: Requires significant force (typically 1,000-2,000 Newtons) directed at the midface, commonly from:

  • Motor vehicle collisions (dashboard or steering wheel impact)
  • Falls from height (>10 feet)
  • Assault with blunt objects
  • Sports injuries (rare, typically contact sports without protective gear)

Clinical Presentation

Patients present with a characteristic constellation of findings:

  • Dish-face deformity (midface retrusion)
  • Cerebrospinal fluid rhinorrhea (cribriform plate involvement)
  • Diplopia (orbital involvement)
  • Malocclusion (dental misalignment)
  • Epistaxis and nasal obstruction
  • Periorbital ecchymosis (“raccoon eyes”)
  • Mobile midface on physical examination

Work RVU (wRVU)

wRVU Value: 23.461

This substantial wRVU reflects:

  • Extensive surgical time (typically 3-6 hours operative time)
  • Technical complexity requiring advanced training in craniofacial surgery
  • Multiple approaches with dissection through different tissue planes
  • Intraoperative decision-making for fracture pattern variations
  • Risk profile including proximity to critical structures (orbit, brain, nasal airway)

For context, this wRVU is comparable to major oncologic resections or complex spinal fusions, placing it in the upper tier of surgical procedures. A single 21347 procedure represents approximately 15-20% of a typical surgeon’s monthly productivity target.

Global Period

Global Days: 090

The 90-day global period includes:

Preoperative Component:

  • History and physical examination (when performed day before or day of surgery)
  • Review of imaging studies (CT maxillofacial, 3D reconstructions)
  • Surgical planning and approach determination

Intraoperative Component:

  • All surgical work including multiple approach exposures
  • Fracture reduction and fixation
  • Closure of all surgical sites

Postoperative Component (within 90 days):

  • Hospital follow-up visits
  • Office visits for wound checks
  • Hardware assessment and occlusion verification
  • Suture/staple removal
  • Management of typical complications (edema, minor infections)
  • Physical therapy coordination for TMJ rehabilitation

NOT Included in Global:

  • Initial emergency department evaluation
  • Preoperative CT imaging
  • Treatment of major complications (hardware failure, infection requiring revision)
  • Unrelated E/M services (use modifier -25)

Assistant Payable

Yes - Assistant-at-Surgery Payable

CPT 21347 qualifies for assistant surgeon reimbursement (typically 16% of the primary surgeon fee) because:

  1. Complexity Tier: Classified as a complex surgical procedure requiring specialized assistance
  2. Multi-handed Requirements: Requires simultaneous retraction, suction, and fragment manipulation
  3. Extended Duration: Procedures exceeding 2 hours benefit from dedicated assistance
  4. Critical Anatomical Proximity: Assistant provides safety margin near neurovascular structures

Modifier Options for Assistants:

  • -80: Assistant surgeon (most common, typically 16% reimbursement)
  • -81: Minimum assistant surgeon (rare, 10% reimbursement)
  • -82: Assistant when qualified surgeon not available (16% reimbursement)
  • -AS: Physician assistant, nurse practitioner, or clinical nurse specialist (payer-specific)

Includes

CPT 21347 is a comprehensive code that bundles:

Surgical Components:

  • Multiple surgical approaches (e.g., coronal + intraoral + subciliary)
  • Soft tissue dissection through all approach sites
  • Subperiosteal elevation of facial and orbital tissues
  • Fracture exposure across all involved bones
  • Anatomic reduction of all displaced fragments
  • Application of fixation hardware:
  • Titanium miniplates (typically 1.3-2.0mm thickness)
  • Screws (self-tapping or self-drilling)
  • Resorbable plates (when indicated)
  • Intermaxillary fixation (IMF) if required for occlusal alignment
  • Arch bars
  • IMF screws
  • Elastic traction
  • Wound closure in layers for all incision sites
  • Drain placement if needed

Postoperative Care:

  • All routine follow-up within 90 days
  • Occlusion checks and adjustments
  • Wire/elastic adjustments
  • Standard wound management

Excludes

The following are separately reportable when documented and medically necessary:

Additional Fracture Repairs:

  • 21395 - Open treatment of orbital floor fracture (blowout)
  • Use modifier -59 or -XS to indicate distinct procedure
  • Common combination in midface trauma
  • 21338-21339 - Nasal bone fracture repair (if distinct from nasomaxillary complex)
  • 21346 - Do NOT report with 21347 (bundled, represents single approach variant)
  • 21421-21423 - Zygomatic arch fractures (if separate injury pattern)

Imaging Studies:

  • 70486 - CT maxillofacial without contrast (preoperative planning)
  • 70487 - CT maxillofacial with contrast
  • 70488 - CT maxillofacial without and with contrast
  • 70336 - MRI temporomandibular joints

Airway Management:

  • 31500 - Emergency endotracheal intubation (if performed separately from anesthesia)
  • 31603 - Tracheostomy (if required for airway management)

Non-Fracture Procedures:

  • 30420 - Rhinoplasty (if cosmetic component separate from fracture repair)
  • 15820-15823 - Blepharoplasty revisions
  • Dental procedures - Crown/bridge work (non-covered by medical insurance)

Relevant ICD-10-CM Codes

Primary Diagnostic Codes:

Maxillary Fractures (Most Specific):

  • S02.401A - Maxillary fracture, unspecified, initial encounter
  • S02.401B - Maxillary fracture, unspecified, initial encounter for open fracture
  • S02.402A - LeFort I fracture, initial encounter
  • S02.411A - LeFort II fracture, initial encounter ← MOST APPROPRIATE
  • S02.412A - LeFort III fracture, initial encounter
  • S02.42XA - Fracture of alveolus of maxilla, initial encounter

Nasal Complex:

  • S02.2XXA - Fracture of nasal bones, initial encounter

Associated Orbital Involvement:

  • S02.3XXA - Fracture of orbital floor, initial encounter
  • S02.85XA - Fracture of orbit, unspecified, initial encounter

Seventh Character Extensions:

  • A = Initial encounter for closed fracture (most common)
  • B = Initial encounter for open fracture (soft tissue compromise)
  • D = Subsequent encounter for fracture with routine healing
  • G = Subsequent encounter for fracture with delayed healing
  • K = Subsequent encounter for fracture with nonunion
  • S = Sequela (late effect)

Important Coding Note:

HCC Status: These fracture codes are NOT Hierarchical Condition Category (HCC) codes. HCC coding applies primarily to chronic conditions for Medicare Advantage risk adjustment, not acute traumatic injuries. Maxillofacial fractures do not persist as risk-adjusting conditions in subsequent years.

Secondary Codes (Etiology):

Document the external cause using Chapter 20 codes:

  • V89.2XXA - Motor vehicle traffic accident, unspecified
  • W19.XXXA - Unspecified fall
  • X99.9XXA - Assault by unspecified sharp object
  • Y08.89XA - Assault by other specified means

Complication Codes (if applicable):

  • T81.4XXA - Infection following procedure, initial encounter
  • T84.216A - Displacement of internal fixation device of facial bones, initial

MS-DRG Assignment

MS-DRG (Medicare Severity Diagnosis Related Group) assignment for 21347 depends on patient complexity and comorbidities:

MS-DRGDescriptionTypical LOSRelative Weight
011Tracheostomy for Face, Mouth & Neck Diagnoses or Laryngectomy with MCC10-14 days3.8-4.2
012Tracheostomy for Face, Mouth & Neck Diagnoses or Laryngectomy with CC6-8 days2.2-2.5
129Major Head & Neck Procedures with CC/MCC or Major Device3-5 days2.1-2.4
130Major Head & Neck Procedures without CC/MCC1-3 days1.4-1.7
157Dental & Oral Diseases with MCC4-6 days1.6-1.9
158Dental & Oral Diseases with CC2-3 days0.9-1.1
159Dental & Oral Diseases without CC/MCC1-2 days0.6-0.8

DRG Optimization Factors:

MCC (Major Complication/Comorbidity) Examples:

CC (Complication/Comorbidity) Examples:

Clinical Documentation Impact:

Proper documentation of complications and comorbidities can shift DRG assignment from 159 (RW ~0.7) to 129 (RW ~2.3), representing a >300% increase in hospital reimbursement. Ensure all clinically present conditions are documented and coded.

Code Tree & Related Procedures

Maxillofacial Fracture Management Hierarchy

FACIAL FRACTURE TREATMENT (21300-21497) │ ├── CLOSED TREATMENT │ ├── 21310 - Nasal bone, closed treatment │ ├── 21315 - Nasal bone with manipulation │ └── 21345 - Nasomaxillary complex, closed treatment │ ├── OPEN TREATMENT - SIMPLE/MODERATE │ ├── 21325 - Nasal bone, open treatment │ ├── 21335 - Nasal septal fracture, open treatment │ └── 21346 - Nasomaxillary complex, open (SINGLE approach) │ └── OPEN TREATMENT - COMPLEX ├── 21347 - Nasomaxillary complex (MULTIPLE approaches) ← YOU ARE HERE ├── 21348 - Nasomaxillary complex with bone grafting ├── 21360 - Malar area, open treatment ├── 21366 - Complicated malar or maxillary fracture ├── 21385 - Orbital floor blowout, periorbital approach ├── 21395 - Orbital floor, internal approach └── 21421-21423 - Palatal or maxillary alveolar ridge fracture

Key Distinctions:

21345 vs 21346 vs 21347:

  • 21345 = Closed treatment (no incision, manipulation only, IMF)
  • 21346 = Open, single approach (typically intraoral OR coronal, not both)
  • 21347 = Open, multiple approaches (≥2 distinct access points)

When to Use 21347:

  • Bilateral fracture patterns requiring symmetric access
  • Combination of coronal + intraoral approaches
  • Need for both orbital rim AND intranasal exposure
  • Complex comminution requiring multiple fixation points
  • Posterior maxillary involvement requiring pterygoid access

Modifiers Commonly Used with 21347

Procedural Modifiers:

-22 - Increased Procedural Services

  • Use when procedure is significantly more complex than typical
  • Examples: Severe comminution, prior failed repair, extensive bone loss
  • Requires detailed operative report justification
  • Typically adds 20-50% to reimbursement

-50 - Bilateral Procedure

  • Generally NOT appropriate (bilateral nature already included in code descriptor)
  • Check payer-specific guidelines

-51 - Multiple Procedures

  • Applied when 21347 is secondary procedure (not first-listed)
  • Automatically reduces reimbursement by 50% for the secondary procedure
  • Sequence highest RVU procedure first

-59 or X{EPSU} - Distinct Procedural Service

  • Use when reporting 21347 with 21395 (orbital floor repair)
  • Use with 21360 (malar fracture) if anatomically distinct
  • Justifies separate payment for procedures that might otherwise be bundled

-62 - Two Surgeons (Co-Surgeons)

  • When two surgeons of different specialties work simultaneously
  • Example: Oral maxillofacial surgeon + neurosurgeon for skull base involvement
  • Each surgeon reports 21347--62 and receives 62.5% of allowed amount
  • Requires separate operative notes from each surgeon

-80 - Assistant Surgeon (discussed above)

-78 - Unplanned Return to OR

  • For complications requiring reoperation within 90-day global period
  • Example: Hardware failure, hemorrhage, infection requiring washout
  • Reimburses at reduced rate (typically 70%)

-79 - Unrelated Procedure During Postoperative Period

  • For new procedures during the 90-day global of 21347
  • Example: New trauma to different facial area
  • Reimburses at 100% (bypasses global period)

Location Modifiers (Facility-Specific):

-LT/-RT - Left/Right

  • Not typically used (bilateral nature inherent to midface)
  • May be required by specific payers for unilateral variant

Documentation Requirements for Optimal Reimbursement

Operative Report Must Include:

  1. Detailed Fracture Description:

  2. Specific bones involved (nasal, maxilla, ethmoid, orbital rims)

  3. Degree of displacement (millimeters)

  4. Comminution pattern (number of fragments)

  5. Involvement of dentition/occlusion

  6. Approach Documentation (CRITICAL for 21347):

  7. MUST clearly describe ≥2 distinct approaches

  8. Example: “Coronal incision extended across scalp for superior orbital rim access. Separately, bilateral intraoral vestibular incisions for anterior maxillary wall exposure.”

  9. Document length and location of each incision

  10. Describe tissue planes dissected for each approach

  11. Reduction Technique:

  12. Method of fragment manipulation

  13. Use of reduction forceps, elevators, or manual pressure

  14. Intraoperative imaging confirmation (C-arm fluoroscopy)

  15. Occlusal verification method

  16. Fixation Details:

  17. Plate locations (e.g., “1.5mm 4-hole plate at right infraorbital rim”)

  18. Number and size of screws

  19. Total number of fixation points

  20. Bone grafting if performed (see 21348)

  21. Time Documentation:

  22. Skin-to-skin time

  23. Critical portions (especially if considering modifier -22)

Example Documentation (Optimal):

“After induction of general anesthesia and nasotracheal intubation, a coronal incision was made extending from one helix to the other. Subperiosteal dissection exposed bilateral supraorbital rims, nasal dorsum, and nasofrontal suture. Separately, bilateral maxillary vestibular incisions were created and subperiosteal tunnels developed to expose the anterior maxillary walls, piriform apertures, and infraorbital rims. The fracture pattern revealed displaced LeFort II fragments with 8mm posterior displacement of the maxilla, bilateral orbital rim step-offs of 4mm, and nasal pyramid deviation. After mobilization, anatomic reduction was achieved using Rowe disimpaction forceps and manual pressure. Occlusion was verified with IMF and found to be class I. Rigid fixation was accomplished using: 2.0mm 6-hole plate at nasofrontal suture, bilateral 1.5mm 4-hole plates at infraorbital rims, and 2.0mm 6-hole plate spanning anterior maxillary wall. Total of 28 self-drilling screws placed. C-arm imaging confirmed anatomic alignment. All incisions closed in layers.”

This documentation clearly justifies 21347 (multiple approaches), supports the wRVU, and defends against downcoding.

Coding Examples with Clinical Context

Example 1: Straightforward LeFort II (Standard 21347)

Clinical Scenario:
28-year-old unrestrained driver in motor vehicle collision. CT shows LeFort II fracture with 6mm displacement, no comminution. No other injuries. Surgery performed on hospital day 2.

Procedure Performed:
Coronal approach for superior access + bilateral intraoral approaches for maxillary fixation. Three plates placed. No complications.

Coding:

  • CPT: 21347
  • ICD-10-CM: S02.411A (LeFort II fracture, initial encounter)
  • External Cause: V89.2XXA (MVC unspecified)
  • Modifiers: None
  • MS-DRG: 130 (Major Head & Neck without CC/MCC)

Expected wRVU: 23.46

Example 2: Complex LeFort II with Orbital Floor Blowout

Clinical Scenario:
42-year-old assault victim with LeFort II + left orbital floor blowout fracture causing enophthalmos and extraocular muscle entrapment. Diplopia present. Surgery day 3 post-injury.

Procedure Performed:
Coronal + bilateral intraoral approaches for LeFort II reduction/fixation. Separately, left transconjunctival approach for orbital floor exploration with titanium mesh placement.

Coding:

  • CPT: 21347, 21395-59 (or XS)
  • ICD-10-CM:
  • S02.411A (LeFort II, initial)
  • S02.3XXA (Orbital floor fracture, initial)
  • H53.2 (Diplopia - secondary code)
  • External Cause: X99.9XXA (Assault by unspecified means)
  • Modifiers: 59 on 21395 to indicate distinct procedure
  • MS-DRG: 129 or 130 (depending on comorbidities)

Expected wRVU: 23.46 + 17.21 = 40.67

Billing Note: The 59 modifier is essential here because some payers might bundle orbital floor repair with nasomaxillary complex treatment. Documentation must clearly show these are distinct anatomic sites with separate approaches.

Example 3: LeFort II with Severe Comminution (Modifier 22)

Clinical Scenario:
35-year-old fell 30 feet from scaffolding. CT shows severely comminuted LeFort II with 10+ fragments, 15mm posterior displacement, significant soft tissue degloving. Patient also has traumatic brain injury (mild, GCS 14) and mandible fracture requiring separate ORIF.

Procedure Performed:
Extended surgery (6.5 hours) requiring coronal, bilateral intraoral, bilateral subciliary approaches due to extreme comminution. Required 8 plates total and bone morphogenetic protein application. Separate mandible ORIF performed.

Coding:

  • CPT:
  • 21347--22 (increased procedural services)
  • 21470 (Mandible ORIF - separate procedure)
  • ICD-10-CM:
  • S02.411B (LeFort II, initial, OPEN fracture due to soft tissue compromise)
  • S02.609A (Mandible fracture, unspecified)
  • S06.0X0A (Concussion, initial)
  • External Cause: W19.XXXA (Unspecified fall)
  • Modifiers: -22 on 21347 (requires special documentation)
  • MS-DRG: 129 (Major Head & Neck with CC/MCC) - the TBI qualifies as MCC

Expected wRVU: 23.46 × 1.3 = 30.50 (with modifier 22 adjustment)

Documentation for Modifier 22:
Must include detailed explanation of why procedure was substantially more difficult:

  • Unusual number of fragments requiring individual fixation

  • Extended operative time (>1.5× typical)

  • Additional approaches beyond typical case

  • Significant blood loss or anatomic distortion

Example 4: Two-Surgeon Approach (Modifier 62)

Clinical Scenario:
50-year-old with LeFort II fracture extending into anterior skull base with CSF leak. Requires simultaneous work by oral maxillofacial surgeon and neurosurgeon.

Procedure Performed:
OMFS and neurosurgeon work simultaneously. OMFS performs facial fracture reduction/fixation via coronal and intraoral approaches. Neurosurgeon repairs dural tear and manages skull base component via same coronal approach.

Coding:

Reimbursement: Each surgeon receives 62.5% of allowed amount for 21347

Documentation: Both surgeons must dictate separate operative reports describing their distinct but simultaneous work.

Example 5: Staged Procedure with Hardware Removal

Clinical Scenario:
Initial LeFort II repair with 21347 performed 6 months ago. Patient now presents for elective hardware removal due to palpable/visible plates causing discomfort.

Procedure Performed:
Removal of maxillary and orbital rim plates via intraoral and subciliary approaches.

Coding:

  • CPT: 20670 (Removal of implant; superficial) or 20680 (deep)
  • ICD-10-CM:
  • T84.84XA (Pain due to internal orthopedic device, initial)
  • Z98.89 (Other specified postprocedural states)
  • Modifiers: 79 if still within 90-day global period of another procedure (unlikely at 6 months)

Note: Do NOT use 21347 for hardware removal. This is specifically for fracture treatment.

Example 6: Pediatric LeFort II (Age Consideration)

Clinical Scenario:
12-year-old with LeFort II from bicycle accident. Developing dentition requires modified fixation approach with resorbable plates to avoid interference with tooth buds.

Procedure Performed:
Coronal + intraoral approaches. Resorbable plate fixation system used instead of titanium to accommodate ongoing craniofacial growth.

Coding:

  • CPT: 21347 (same code regardless of hardware type)
  • ICD-10-CM:
  • S02.411A (LeFort II)
  • External Cause: V10.4XXA (Pedal cyclist injured)
  • Modifiers: None required

Documentation Note: Should specify use of resorbable fixation and rationale (pediatric patient, developing dentition). This doesn’t change the code but supports medical necessity.

Special Considerations & Clinical Pearls

Timing of Surgical Intervention

Optimal Window: Days 3-10 post-injury

  • Too Early (Days 0-2): Excessive edema obscures anatomy, difficult reduction
  • Ideal (Days 3-10): Edema resolving but fractures not yet consolidated
  • Late (>14 days): Early bony union, may require re-fracture (osteotomy)

Delayed Presentation (>21 days):

  • May require 21348 (with bone grafting) instead of 21347
  • Consider malunion codes if fracture healed in non-anatomic position
  • May need modifier 22 for increased difficulty

Anesthesia Considerations

  • Nasotracheal intubation typical (allows assessment of occlusion)
  • Oral RAE tube alternative
  • Tracheostomy rare, but code separately if required: 31603
  • Fiberoptic intubation often necessary due to facial distortion
  • Anesthesia code: 00192 (Anesthesia for facial bone fracture repair)

Blood Loss & Transfusion

  • Expected blood loss: 200-800 mL
  • Transfusion required in ~15-20% of cases
  • If transfusion given, code separately:
  • 36430 (Transfusion, blood or blood components)
  • Add ICD-10: D62 (Acute posthemorrhagic anemia) for DRG impact

Postoperative Management

Immediate (Days 0-3):

  • ICU or step-down monitoring if concern for airway compromise
  • Head elevation 30-45 degrees
  • Periorbital ice packs
  • Soft/liquid diet
  • Prophylactic antibiotics (controversial, but common practice)

Early (Weeks 1-6):

  • Weekly occlusion checks
  • IMF release typically at 4-6 weeks
  • Soft diet continues 6-8 weeks
  • Physical therapy for TMJ if indicated: 97110 (Therapeutic exercises)

Late (Weeks 6-12):

  • Return to normal diet
  • Final occlusion assessment
  • CT imaging if malunion suspected: 70486
  • Consider hardware removal at 6-12 months if symptomatic

Common Complications (Outside Global Period)

ComplicationIncidenceSecondary CodeTreatment Code
Infection (superficial)5-10%T81.4XXA10180 (I&D)
Hardware failure2-5%T84.216A20680 (removal) + possible re-ORIF
Malunion3-8%M84.831A21141-21143 (Osteotomy)
Enophthalmos10-15%H05.40921260 (Orbital augmentation)
Diplopia (persistent)5-10%H53.267311-67316 (Strabismus surgery)
TMJ dysfunction15-25%M26.6297110 (PT) or 29800 (Arthroscopy)
Infraorbital anesthesia20-40%G50.9Observation (usually resolves)
Telecanthus5-10%Q10.0 (if congenital), S02.2XXS (sequela)21263 (Canthopexy)

Conversion to Other Codes

When NOT to Use 21347:

❌ Single approach only → Use 21346
❌ Closed reduction, no incisions → Use 21345
❌ Bone grafting performed → Use 21348
❌ LeFort I pattern (lower maxilla only) → Use 21422-21423
❌ LeFort III pattern (complete craniofacial separation) → Use 21431-21436
❌ Delayed presentation with malunion → Use osteotomy codes 21141-21145
❌ Secondary cosmetic revision → Use rhinoplasty codes 30400-30450

Payer-Specific Issues

Medicare:

  • Covers 21347 as medically necessary for acute fracture
  • Requires clear documentation of “multiple approaches”
  • May bundle certain related procedures (check NCCI edits)

Medicaid:

  • Coverage varies by state
  • Some states require prior authorization for procedures >$5,000
  • May have restrictions on hardware type (require justification for resorbable)

Commercial Payers:

  • Generally cover without prior auth for acute trauma
  • May request operative report to verify “multiple approaches”
  • Some require modifier -59 for add-on procedures like 21395

Documentation Requirements

  • Detailed description of fracture patterns
  • Specific surgical approaches used
  • Fixation techniques and materials
  • Rationalization for using multiple approaches
  • Postoperative care plan

Conclusion

CPT 21347 is utilized for the vast and intricate procedures required to treat complex nasomaxillary fractures, emphasizing the need for extensive documentation and precise coding to ensure proper billing and reimbursement.

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