🧬CPT Code 21348: Open Treatment of Nasomaxillary Complex Fracture (LeFort II) with Bone Grafting

Overview

CPT code 21348 describes the open treatment of a nasomaxillary complex fracture (LeFort II type) with bone grafting, including obtaining the graft. This procedure represents a high-complexity facial trauma repair where the pyramidal midface fracture requires not only open reduction and internal fixation (ORIF) via rigid plate fixation but also supplemental bone grafting to reconstruct missing or severely comminuted bone segments. The bone graft is harvested during the same operative session and incorporated into the surgical reconstruction—the “including obtaining the graft” component is bundled into the code.

Clinical Context

A LeFort II fracture with bone grafting indicates a more severe injury pattern than simple ORIF alone. This typically occurs when:

Significant bone loss or comminution exists
Fracture lines extend through areas requiring vertical support (nasofrontal junction, orbital rims)
Pterygoid plates are fractured or fragmented
Posterior maxillary segment requires structural support to prevent dish-face deformity
Non-union risk is high without structural graft support

Think of 21348 as the “reconstructive” tier of LeFort II management, distinguishing it from 21346 (plate fixation only) and 21347 (multiple approaches without grafting).

Clinical Anatomy & Pathophysiology

LeFort II Fracture Pattern (Pyramid Fracture)

The LeFort II fracture, first described by René Le Fort in 1901, is characterized by a pyramidal fracture pattern that separates the upper midface from the cranial base:

Fracture Lines:

Superior boundary: Passes through the nasofrontal suture and anterior nasal bones
Lateral boundaries: Extend through the medial orbital walls (ethmoid region) and continue through the infraorbital rims bilaterally
Inferior boundary: Crosses the anterior maxillary walls, typically above the apices of the upper teeth
Posterior extent: Communicates through the pterygoid plates posteriorly

Anatomical Consequences:

Separation of the midface pyramid (nose, medial orbits, upper teeth-bearing maxilla) from the cranial base
Loss of vertical support causing anterior-posterior maxillary displacement (typically posterior)
Potential involvement of cribriform plate (risk of CSF leak)
Disruption of occlusion and anterior-posterior jaw relationships
Risk of enophthalmos if orbital volume altered

Bone Loss Patterns Requiring Grafting

Situations where 21348 (with grafting) is necessary instead of 21346 (fixation only):

Comminuted Fractures (10+ fragments):
Multiple fracture lines create segmentation
Bone fragments insufficient for anatomic reconstruction without added support
Common in high-velocity mechanisms (MVC, falls >20 feet)
Pterygoid Plate Involvement:
Fracture extends to pterygoid plates (posterior maxilla)
Loss of posterior vertical dimension without graft support
Often the indication for graft material
Cribriform Plate/Nasal Support Loss:
Anterior nasal bones completely comminuted or avulsed
Loss of nasal support projection
Graft restores height and anterior-posterior projection
Segmental Loss:
Bone fragments too small or separated to be reliably fixed
Void spaces between fixation points
Graft fills voids and provides structural support
NOE Complex (Nasoorbitalethmoid) Involvement:
When fracture extends to involve nasal-orbital-ethmoid region
Loss of intercaninality support
Medial canthal ligament attachment concerns

Work RVU (wRVU)

wRVU Value: 26.73^{CMS MPFS}

This substantial wRVU reflects the increased complexity of 21348 compared to simpler LeFort II codes:

RVU Comparison (LeFort II Management Spectrum):

21345 (Closed treatment with IMF) = ~2.05 wRVU
21346 (Open treatment, single approach, no graft) = ~23.46 wRVU
21347 (Open treatment, multiple approaches, no graft) = ~23.46 wRVU
21348 (Open with bone grafting) = 26.73 wRVU ← Highest tier
21436 (LeFort III with grafting) = ~31.00 wRVU

Work Components Reflected:

Extended surgical time (typically 4-7 hours total)
Complexity of assessing bone loss and graft requirements
Graft site selection and harvesting (iliac crest most common)
Two surgical fields (harvest site + facial injury site)
Technical skill in graft shaping, positioning, and fixation
High-risk anatomy (proximity to orbits, brain, neurovascular bundles)

2026 Reimbursement Implications^{CMS MPFS}:
Using estimated 2026 conversion factor (~$33.58):

Base wRVU value: 26.73
Total RVU (with practice expense and malpractice): ~30-32
Estimated Medicare allowable: ~ $1, 010 -$ 1,075 (facility setting varies)
Geographic practice cost index (GPCI) applies: 0.80-1.25 multiplier

Global Period

Global Days: 090

The comprehensive 90-day postoperative global period includes:

Preoperative Phase

Consultative E/M visit (typically within 24 hours of surgery)
Review of diagnostic imaging (CT maxillofacial, 3D reconstructions)
Graft site selection assessment (iliac crest, rib, allograft decision)
Discussion of surgical plan and graft options
Risks, benefits, and alternatives discussion documented

Intraoperative Phase

All surgical work for fracture reduction and fixation
Bone graft harvesting (including local anesthesia at graft site if different from facial incisions)
Graft preparation and shaping
Graft positioning and incorporation with fixation
All closure and hemostasis

Postoperative Phase (within 90-day global)

Day 1-3 hospital visits (if inpatient)
Postoperative office visits: 1 week (suture removal), 2-3 weeks, 4-6 weeks (graft incorporation check)
Assessment for infection or hematoma at graft and facial sites
Radiographic assessment of fracture healing and graft incorporation
Functional/occlusal verification
Drainage management if drains placed
All routine postoperative care and complications management

NOT Included in Global Period:

Initial emergency department evaluation (separate E/M code)
Diagnostic imaging (coded separately with modifier -26 for professional interpretation)
Major complications requiring extended ICU stay (use modifier -79)
Unrelated E/M services (use modifier -25)

Assistant Payable

Yes — Assistant-at-Surgery Fully Justified

21348 routinely qualifies for assistant surgeon reimbursement due to:

Extended operative time (4-7 hours typically exceeds 2-hour threshold for assistant consideration)
Two-field surgery complexity (managing both graft harvest site and facial fracture site)
Bone graft manipulation requirements (holding, shaping, positioning graft while surgeon places fixation)
Hemostasis demands (multiple bleeding points from graft site and extensive dissection)
Anatomic complexity (proximity to orbit, brain, neurovascular structures requires constant vigilance)

Assistant Surgeon Responsibilities

During Graft Harvest Phase:

Exposing and developing the graft harvest site (typically iliac crest)
Retraction of soft tissues and periosteum
Measuring and marking graft dimensions
Protecting surrounding neurovascular structures
Hemostasis at harvest site

During Fracture Repair Phase:

Retracting soft tissues for fracture visualization
Applying reduction forceps or traction
Positioning graft material
Holding reduction while plates/screws are placed
Managing hemorrhage
Wound management and closure assistance

Modifier Usage for Assistants

80 - Assistant surgeon (standard, 16% of allowed amount)
81 - Minimum assistant surgeon (rare, 10% of allowed)
82 - Assistant when qualified surgeon not available (16%)

Example Calculation:

Medicare allowed amount for 21348: $1,000
Assistant 80 reimbursement: $160 (16$ 1,000)

Includes

CPT 21348 encompasses the complete episode of open treatment of nasomaxillary complex fracture with bone grafting:

Surgical Components

Preoperative Planning:

Assessment of bone loss extent via imaging
Decision-making regarding graft source (autograft iliac crest, rib, calvarium; allograft; synthetic options)
Surgical sequencing (which site first—graft harvest or facial fracture?)
Patient optimization for extended surgery

Primary Fracture Site Approach:

Intraoral vestibular incisions (or coronal incisions, or combination)
Subperiosteal dissection to expose fracture lines
Identification and protection of neurovascular structures (infraorbital nerve, anterior/posterior superior alveolar vessels)
Mobilization of fractured segments

Fracture Reduction:

Achieving anatomic alignment of nasofrontal region
Restoration of nasal height and projection
Reduction of orbital rim step-offs
Verification of occlusal relationships
Palpation for adequate reduction and mobility assessment

Bone Graft Harvesting (Included):

Selection and exposure of graft source (iliac crest ~70% of cases, rib ~15%, calvarium ~5%, allograft ~10%)
Preparation of donor site (careful cortical/cancellous split if needed)
Graft size assessment matching defect dimensions
Hemostasis at harvest site
Closure of harvest site

Graft Application:

Shaping of graft to conform to fracture anatomy
Positioning of graft to fill bone defects
Integration of graft with existing bone and fracture segments
Plate and screw fixation applied across/through graft as needed
Stabilization ensuring graft won’t shift or dislodge

Fixation Application:

Titanium plates (1.3-2.4mm thickness)
Screws placed through graft and into underlying bone
Typically 2-4 plates at strategic buttresses (nasofrontal, bilateral infraorbital, anterior maxillary)
Compression plating techniques when appropriate

Verification and Closure:

Assessment of reduction adequacy (clinical exam, imaging if intraoperative C-arm available)
Facial symmetry verification
Occlusal relationship assessment
Layered closure of all surgical sites

Postoperative Care (Within 90-day Global)

Graft incorporation monitoring (typically reaches 70-80% incorporation by 6-8 weeks)
Fracture healing assessment via serial radiographs
Management of postoperative swelling and hematoma
Infection surveillance
Suture/staple removal

Excludes

The following are NOT included in 21348 and must be coded separately:

21345 - Closed treatment with IMF (non-operative management)
21346 - Open treatment without bone grafting (do NOT report with 21348)
21347 - Open treatment with multiple approaches but without bone grafting
21395 or 21407/21408 - Orbital floor fracture repair (if distinct from nasomaxillary pattern)
Use modifier 59 (distinct procedural service)
21360/21365/21366 - Zygomatic arch or malar area fractures (if separate from LeFort pattern)

Bone Graft Codes

20900 or 20901 - Do NOT report separately (graft harvesting included in 21348)
20902 - Bone graft for spinal fusion (different anatomic site)

Imaging and Diagnostic Services

70450 - CT head (preoperative planning)
70486/70487/70488 - CT maxillofacial (various phases)
71020 - Chest X-ray (if polytrauma assessment)
82087 - Blood work or labs

Must be coded separately with modifier 26 (professional interpretation) or 59 (distinct service) if billed by same surgeon.

Anesthesia

00192 - Anesthesia for facial bone fracture repair
Billed separately under anesthesia provider codes

Concurrent Procedures

99213/99214/99215 - E/M services unrelated to fracture (use modifier 25)
20670/20680 - Hardware removal (separate future procedure)
97110 - Physical therapy exercises (if ordered postoperatively)

Relevant ICD-10-CM Diagnosis Codes

Primary Nasomaxillary/Maxillary Fracture Codes

CPT 21348 describes the open treatment of a nasomaxillary complex fracture (LeFort II type) with bone grafting, including obtaining the graft.

The appropriate ICD-10-CM diagnosis codes identify the injury location, fracture type, and encounter status:

LeFort II/Nasomaxillary Complex:

S02.4XXA - Fracture of malar and maxillary bones, initial encounter
S02.411A - Maxillary fracture, right side, closed, initial encounter
S02.412A - Maxillary fracture, left side, closed, initial encounter
S02.413A - Maxillary fracture, bilateral, closed, initial encounter
S02.4XXB - Maxillary fracture, open, initial encounter

Nasal/Nasofrontal (if concurrently documented):

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

Orbital Involvement (if present):

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

7th Character Extensions (Mandatory)

A = Initial encounter for closed fracture (when bone breaks but no skin breach)
B = Initial encounter for open fracture (when fractured bone has skin penetration/communicates with external environment)
D = Subsequent encounter for fracture with routine healing (used in postoperative follow-ups within 90-day period)
G = Subsequent encounter for fracture with delayed healing (used if healing slower than expected, typically >12 weeks)
K = Subsequent encounter for fracture with nonunion (used if fracture fails to heal after 4-6 months)
S = Sequela (late effects or complications from old fracture)

Coding Timing Rule: At the operative visit where 21348 is performed, the ICD-10 code uses the appropriate 7th character based on fracture type (A or B). Subsequent follow-up visits within the 90-day global period use 7th character D (routine healing).

Associated Injury Codes

Document concurrent injuries when present:

S06.9XXA - Traumatic brain injury (if concurrent head trauma)
S02.61XA/S02.65XA - Mandible fracture (if bilateral injuries)
R40.20X - Coma of unspecified level, initial
G96.00 - Cerebrospinal fluid leak (if anterior cranial fossa breach/CSF rhinorrhea)

External Cause Codes (Chapter V80-Y99)

Document mechanism of injury (required for trauma coding accuracy):

V89.2XXA - Motor vehicle traffic accident, unspecified (MVC)
W19.XXXA - Unspecified fall
X99.9XXA - Assault by unspecified means
V10.4XXA - Pedal cyclist injured in traffic accident
W03.XXXA - Other fall on same level due to collision with another person

HCC Status (Important Note)

Hierarchical Condition Categories (HCC): Maxillary and nasomaxillary fracture diagnosis codes are NOT HCC-coded conditions. HCC coding applies to chronic diseases used in Medicare Advantage and other risk-adjustment programs. Acute traumatic injuries, including complex midface fractures, do not generate risk scores for capitated care arrangements. These codes are used for accurate encounter coding and episode-of-care documentation only.

MS-DRG Assignment

When 21348 is billed in an inpatient hospital setting (patient admitted and surgery performed during admission), the Medicare Severity Diagnosis Related Group (MS-DRG) assignment affects institutional reimbursement:

Primary Applicable MS-DRGs

MS-DRG	Description	RW	Typical LOS	When Assigned
011	Tracheostomy for Face/Mouth/Neck Diagnoses or Laryngectomy with MCC	3.8-4.2	12-18 days	Concurrent MCC present
012	Tracheostomy for Face/Mouth/Neck Diagnoses or Laryngectomy with CC	2.2-2.5	8-10 days	Concurrent CC present
129	Major Head & Neck Procedures with CC/MCC or Major Device	2.1-2.4	4-6 days	Complex case, moderate comorbidity
130	Major Head & Neck Procedures without CC/MCC	1.4-1.7	2-3 days	Uncomplicated isolated fracture
157	Dental & Oral Diseases with MCC	1.6-1.9	4-6 days	Rare for trauma
158	Dental & Oral Diseases with CC	0.9-1.1	2-3 days	Rare for trauma
159	Dental & Oral Diseases without CC/MCC	0.6-0.8	1-2 days	Rare for trauma

DRG Selection Logic

Principal Diagnosis Impact:

The ICD-10 code for the LeFort II fracture typically triggers assignment to the 129/130 range (Head & Neck Procedures) rather than 157/159 (Dental), though this varies by institutional coding practices and secondary diagnoses

Complication/Comorbidity (CC/MCC) Escalation:

Examples of MCC (increases to DRG 011-012):

S06.0X0A/S06.1X0A - Traumatic subdural or epidural hematoma
J96.00 - Respiratory failure requiring mechanical ventilation
I50.9 - Heart failure decompensation
R65.20 - Severe sepsis with septic shock

Examples of CC (increases to DRG 129):

E11.XX - Type 2 diabetes with complications
J44.X - COPD exacerbation
N18.XX - Chronic kidney disease stage 3-4
F32.9 - Major depressive disorder

Scenario Examples:

Isolated LeFort II with bone graft, age 32, no comorbidities:
DRG: 130 (Major Head & Neck without CC/MCC)
Relative Weight: 1.4-1.7
Expected LOS: 2-3 days
LeFort II with bone graft + TBI (S06.0X0A) requiring ICU monitoring:
DRG: 011 (Tracheostomy with MCC) or 129
Relative Weight: 2.1-4.2
Expected LOS: 4-18 days (depends on TBI severity)
LeFort II with bone graft + COPD exacerbation requiring oxygen:
DRG: 129 (Major Head & Neck with CC/MCC)
Relative Weight: 2.1-2.4
Expected LOS: 4-6 days

DRG Optimization Strategies

Documentation Emphasis:

Clearly identify all clinically significant comorbidities present
Document management of secondary conditions (diabetes glucose control, COPD management, etc.)
Code all complications discovered during hospitalization
Ensure complete capture of present-on-admission (POA) indicators

Expected Reimbursement Impact:

Proper MCC documentation can increase DRG payment from $2, 200 (D RG 130) t o$ 7,500-$8,500 (DRG 011)—a 250-300% increase
Critical to ensure accurate and complete secondary diagnosis coding

Code Tree & Hierarchical Relationships

LeFort II Management Spectrum

NASOMAXILLARY COMPLEX FRACTURE (LeFort II) MANAGEMENT │ ├── CLOSED TREATMENT │ ├── 21345 - No manipulation (immobilization only) │ └── 21345 - With interdental fixation (IMF/arch bars/wires) │ ├── OPEN TREATMENT - NO GRAFTING │ ├── 21346 - Single surgical approach │ │ └── Typical: Intraoral OR coronal incision │ │ └── Plate fixation, no bone support │ │ │ └── 21347 - Multiple surgical approaches │ └── Typical: Coronal + intraoral + subciliary │ └── Extended dissection, multiple fixation points │ └── OPEN TREATMENT - WITH BONE GRAFTING ├── 21348 - Multiple approaches + bone graft ← YOU ARE HERE │ └── Bone loss/comminution requiring structural support │ └── Typically 4-7 hour procedure │ └── Highest wRVU (26.73) │ ├── 21436 - LeFort III (craniofacial separation) + grafting │ └── More extensive than LeFort II │ └── Complete midface-to-cranium separation │ └── Even higher wRVU (~31.00) │ └── 20900/20901 - NEVER code separately with 21348 └── Graft harvesting is bundled/included

Key Distinctions: When Each Code Applies

Feature	21346	21347	21348
Bone Grafting	No	No	Yes
Surgical Approach(es)	Single	Multiple	Multiple
Comminution	Minimal	Moderate	Severe
Pterygoid Involvement	Usually not	Possible	Common
Operative Time	2-3 hours	3-5 hours	4-7 hours
wRVU	23.46	23.46	26.73
When to Use	Good bone stock, minimal displacement	Multiple fracture sites, complex pattern	Bone loss, segmental comminution

Decision Tree for Code Selection

LeFort II Fracture Presentation
│
├─→ Open reduction needed?
│   │
│   ├─ NO → Use [[21345]] (closed treatment)
│   │
│   └─ YES → Continue
│
├─→ Multiple surgical approaches required?
│   │
│   ├─ NO (single approach) → Continue
│   │
│   └─ YES (≥2 approaches) → Continue
│
├─→ Significant bone loss or severe comminution?
│   │
│   ├─ NO → Use [[21346]] or [[21347]] (no grafting)
│   │
│   └─ YES → Use [[21348]] (WITH bone grafting)

Modifiers Commonly Used with CPT 21348

Procedural Modifiers

-22 - Increased Procedural Services

Use when procedure complexity significantly exceeds typical 21348 case
Examples: Extreme comminution (15+ fragments), massive bone loss requiring large allograft, concurrent reconstructive procedures
Requires explicit documentation of additional complexity
Typically increases reimbursement 20-50%
Risk: Overuse invites audits; use judiciously and only with clear justification

-50 - Bilateral Procedure

Generally NOT appropriate for 21348
LeFort II is anatomically considered a unilateral “pyramid” despite bilateral involvement
Check payer-specific guidelines; most Medicare MACs do NOT support bilateral modifier
If used, must demonstrate that procedure required for both sides as distinct fractures

-51 - Multiple Procedures (Reduction for Secondary Procedure)

Use when 21348 is reported as secondary to another higher-wRVU procedure
Automatic 50% reduction to the secondary procedure
Sequence primary procedure first (highest wRVU)
Example: Primary 21470 (mandible, multiple approaches), secondary 21348

-59 / X{EPSU} - Distinct Procedural Service

Use when reporting 21348 with related but distinct procedures
Examples:
21348 + 21360 (zygomatic arch repair, separate approach)
21348 + 21395 (orbital floor repair)
21348 + 21445 (alveolar ridge fracture, separate surgical field)
Justifies separate reimbursement when bundle edits would normally apply

Anatomically-Specific NCCI Modifiers:

-XE - Separate encounter
-XP - Separate patient
-XS - Separate structure (most common for facial procedures)
-XU - Unusual non-overlapping service

-62 - Two Surgeons (Co-Surgeons)

When two surgeons of different specialties perform procedure jointly
Example: Oral maxillofacial surgeon + neurosurgeon (if skull base involvement)
Each surgeon bills 21348--62
Each receives 62.5% of allowed amount
Requires separate operative notes from each surgeon

-76 - Repeat Procedure, Same Surgeon

Unplanned return to operating room within 90-day global period
Example: Hardware failure, inadequate reduction requiring redo
Reduced reimbursement (~70% of standard)

-77 - Repeat Procedure, Different Surgeon

Same scenario as -76, but different surgeon performs repeat
Reduced reimbursement (~70%)

-78 - Unplanned Return to OR During Global Period

For intraoperative complications requiring return to surgery
Example: Graft site hemorrhage requiring additional hemostasis
Reduced reimbursement (~70%)

-79 - Unrelated Procedure During Global Period

For new surgical problem unrelated to the fracture
Example: New trauma to different facial area during 21348 recovery period
100% reimbursement (not subject to global period restrictions)

-80 - Assistant Surgeon (Discussed Above)

Standard for 21348
16% of allowed amount

-81 - Minimum Assistant Surgeon

Limited assistance only (rare for 21348)
10% of allowed amount

Anatomical Modifiers (Payer-Dependent)

-LT/-RT - Left/Right

Most payers do NOT require for LeFort II (bilateral midface structure)
Check carrier-specific LCD (Local Coverage Determination)
If carrier requires: 21348--RT or 21348--LT

Bone Graft Sources and Selection

Understanding graft materials is critical because 21348 includes obtaining the graft—the choice of source impacts operative time, complexity, and tissue response:

Autogenous Bone Grafts (Most Common, ~70% of cases)

Iliac Crest (Most Frequent Choice):

Source: Anterior or posterior superior iliac spine
Bone quality: Excellent—high cancellous:cortical ratio
Quantity available: Large; 30-50 mL typical harvest
Resorption: Moderate (~30% at 1 year)
Complications: Chronic pain (10-20%), gait disturbance (5%), hematoma (2-5%)
Operative time addition: +45-60 minutes
Cost: Minimal (no additional implant cost)

Rib Graft:

Source: Rib 5-7 (best cortical bone)
Bone quality: Excellent cortical structure
Quantity available: Moderate; 15-20 mL
Resorption: Less than iliac (~15-20% at 1 year)
Complications: Pneumothorax risk (<1%), pleural injury
Operative time addition: +30-45 minutes
Cost: Minimal
Advantage: Structural rigidity from cortical component
Disadvantage: Requires thoracic exposure; higher complication risk

Calvarium (Skull):

Source: Split-thickness from parietal or occipital bone
Bone quality: Excellent cortical structure
Quantity available: Limited; 5-15 mL
Resorption: Minimal (~5% at 1 year)
Advantages: Least resorption; excellent for structural needs
Disadvantages: Neurosurgery expertise required; risk of dural injury
Operative time addition: +60-90 minutes
Cost: Minimal

Allogeneic (Cadaveric) Bone Grafts (~15% of cases)

Demineralized Bone Matrix (DBM):

Source: Processed cadaveric bone
Structure: Cancellous or cortical available
Handling: Ready-to-use; no harvest site morbidity
Osteoinductivity: Variable, depends on processing
Resorption: Complete within 6-12 months
Disease transmission risk: <1 in 1.6 million (extremely low)
Cost: Moderate ( $500 -$ 2,000 per unit)
Best use: Filling gaps; requires host bone for complete fusion

Freeze-Dried Bone (FDB):

Advantages: Shelf-stable, no tissue reaction
Disadvantages: Slower incorporation; reduced osteoinductivity
Cost: Moderate

Synthetic/Allograft Alternatives (~10% of cases)

Hydroxyapatite:

Composition: Ceramic mimicking mineral phase of bone
Integration: Osteoconductive (not osteoinductive)
Resorption: Minimal to none
Best use: Defect filling, dimensional support
Cost: Moderate

Biphasic Calcium Phosphate (BCP):

Composition: Mix of hydroxyapatite and beta-tricalcium phosphate

Coding examples

Example 1 - Acute LeFort II with bone loss

Scenario
- Polytrauma patient with comminuted LeFort II midface fracture and segmental bone loss of the anterior maxillary wall and infraorbital rim.
- Surgeon performs coronal and intraoral approaches, reduces fractures, plates facial buttresses, and harvests split calvarial bone graft to reconstruct the infraorbital rim and maxillary wall.
CPT
- 21348 - Single unit covers: open reduction, internal fixation, and bone grafting (including graft harvest) for the LeFort II complex.^2,4,5
Assistant
- If a physician assistant surgeon is present for much of the case: assistant reports 21348 -80 (or -81 for minimal assist) when MPFS assistant indicator allows and necessity is documented.
- If NPP assists: 21348 AS on the NPP claim instead of physician assistant modifiers.^1,8
ICD-10-CM
- Principal injury diagnosis example: S02.4XXA-series (fracture of malar and maxillary bones) with appropriate 7th character and laterality per documentation.
- External cause: e.g., V89.2XXA if MVA, or Y04.0XXA if assault, etc., as clinically appropriate.

Example 2 - Secondary midface reconstruction

Scenario
- Patient with malunited LeFort II fracture from remote trauma causing midface retrusion and occlusal changes.
- Surgeon performs osteotomies to re-create fracture lines, repositions midface, applies rigid fixation, and uses iliac crest bone grafts to augment anterior maxilla and nasal base.
CPT
- 21348 - Used when the surgeon is essentially re-treating the LeFort II nasomaxillary complex with open reduction and bone grafting to restore midface support.
- Additional orthognathic codes (e.g., 21141-21147) could be considered only if a separate formal orthognathic procedure is performed and not simply part of the LeFort reconstruction, subject to NCCI edits and payer policy.
ICD-10-CM
- Sequela or subsequent encounter codes from the S02.4- series with appropriate 7th character (e.g., S02.4XXS for sequela) plus symptom/occlusion codes (e.g., M26.4-) as documented.

Explorer

21348