Oral Surgery Coding & Reimbursement Alert

Published on Tue Feb 24, 2015 PDF

Watch CCI edits for reporting different fracture treatment methods in different sites.

When you’re coding mandibular fractures, you will need train your sights on the anatomical location of the fracture, the type of treatment that your oral surgeon performs, and the type of fixation that he uses to zero in on the right code for the procedure. Follow five tips for accurate claims. 

1. Choose From Different Code Sets Depending on Site of Fracture

When your oral surgeon treats a fracture of the mandible, you will have to first look for details on the fracture site.  You have three broad code sets to choose from depending on where the fracture on the mandible was present:

• Alveolar ridge (21440-21445)
• Mandibular condyle (21465, Open treatment of mandibular condylar fracture)
• Any other part of the mandible (21450-21462)

2. Watch Type of Fracture Reduction 

Once you have the anatomical location code set identified, choose the appropriate code depending on whether your surgeon performed the reduction of the fracture using an open method or a closed treatment. “It is important to consider time to reduce or repair a fracture, the number of plates used, and the extent of the fracture,” suggests Barry Shipman, DMD, clinical professor, University of Florida School of Dentistry, Hialeah Dental Center. “This can be reflected in the codes 21450-21462.”

For fractures of the alveolar ridge, you will choose 21440 (Closed treatment of mandibular or maxillary alveolar ridge fracture [separate procedure]) when your surgeon performed a closed reduction of an alveolar ridge fracture. You report 21445 (Open treatment…) when your oral surgeon performs an open treatment of an alveolar ridge fracture.

Similarly, you choose a code from the range, 21450-21453 for fractures of the mandible where your surgeon used a closed treatment to handle the fracture. For open reduction of mandibular fractures, you will have to choose a code from 21454-21470.

Caveat: When your clinician uses a percutaneous approach to treat the fracture, you will have to report the procedure with 21452 (Percutaneous treatment of mandibular fracture, with external fixation). This method will involve your clinician making a small puncture wound to approach the fracture site and placement of a lag screw to hold the fractured parts of the mandible together.

3. Fixation Type Determines Your Code Choice

For open treatment of a mandibular fracture, the last step  is to see what kind of fixation your oral surgeon used. “The use of plates, arch bars, external fixation, and pin fixation are all possible fixation devices that depend on the extent of the fracture,” adds Shipman. Depending on the type of fixation used, you will have to report from one of the following codes:

• 21454 (Open treatment of mandibular fracture with external fixation)
• 21461 (Open treatment of mandibular fracture; without interdental fixation)
• 21462 (…with interdental fixation)
• 21470 (Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints)

“The use of an oral surgical splint (21085, Impression and custom preparation; oral surgical splint) can also be considered if your surgeon makes an impression of the dental arch, designs and fabricates the splint himself,” says Shipman. “However, most fractures do not allow this.” 

Example: Your oral surgeon reviews a 25-year-old male patient who has sustained an injury to the mandible due to a collision with another person when playing football. The patient complains of pain, some degree of paresthesia of the lower lip on the right side. Upon examination, your clinician notes the presence of a unilateral open bite. Your surgeon notes that there is no evident injury to the teeth, although occlusion of the teeth seems to be affected.

Your clinician orders imaging studies that show a transverse fracture of the angle of the mandible with slight displacement. Your clinician decides to perform an open reduction of the fracture with placement of a single 2.0 miniplate. You report 21454 for the surgical reduction of the fracture that your clinician performed.

4. Don’t Forget to Report Appropriate Diagnosis Codes

To support the necessity of performing a surgical reduction of a mandibular fracture, you will have to include the appropriate diagnosis code, depending on whether the fracture was a closed or open one and also indicate the fracture site.  For closed fractures of the mandible, you will have to report an appropriate code from 802.2x (Closed fracture of mandible), whereas you will use 802.3x (Open fracture of mandible) for open fractures of the lower jaw.

Depending on the site of fracture, you will have to use a 5th digit expansion to 802.2x and 802.3x. For example, if you are reporting an closed fracture of the alveolar ridge of the mandible, you will have to report 802.27 (Closed fracture of alveolar border of body of mandible) whereas you will have to use 802.35 (Open fracture of angle of jaw) to report a diagnosis of open fracture of the angle of the mandible.

ICD-10: When reporting the diagnosis of a mandibular fracture using ICD-10 codes, you will have to begin with S02.6 (Fracture of mandible). You will have to use appropriate 6th digit expansion depending on the site of fracture. For identification of whether your surgeon is handling an open or a closed fracture site, you will have to use a 7th digit expansion. This expansion will also indicate whether your surgeon treated the fracture site for the first time or in a subsequent encounter. You will have to choose from the following options for the 7th digit expansion:

• A = initial encounter for closed fracture
• B = initial encounter for open fracture
• D = subsequent encounter for fracture with routine healing
• G = subsequent encounter for fracture with delayed healing
• K = subsequent encounter for fracture with nonunion
• S = sequel

For example, if your surgeon identifies the site as a closed fracture of the ramus of the mandible, you will have to report S02.64XA (Fracture of ramus of mandible, initial encounter for closed fracture) whereas you will report S02.65XB (Fracture of angle of mandible, initial encounter for open fracture) when your clinician treats an open fracture of the angle of the mandible.

5. Focus on CCI For Fracture Treatments at Different Sites

Since a fracture of the mandible can occur at different sites, your clinician might have to treat each of these fractures using different methods. When your surgeon treats two different fractures sites using different surgical approaches, you will have to pay heed to Correct Coding Initiative (CCI) edits, as many of these codes that you use for different surgical treatments for reduction of mandibular fractures are bundled.

For instance, you will face bundling if you are trying to report 21445 with 21462. You will also face such edits when trying to report other fracture treatment procedures such as when reporting 21465 with 21454.

Modifier Indicator: In many of the instances involving reporting two fracture treatment procedures together, the modifier indicator for the edit bundles is ‘1,’ which means you can undo the edits by using a suitable modifier. The modifier that you will have to append to the code that is listed in the column 2 of the CCI edits is 59 (Distinct procedural service).