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2025 CPT code 21480

Closed treatment of temporomandibular dislocation; initial or subsequent.

Adhere to all CPT coding guidelines related to fracture and dislocation treatment. Properly append modifier 76 if subsequent reduction is performed by the same provider. Modifier 54 should be appended if the provider performing the initial treatment will not be providing subsequent treatment.

Modifiers 76 (repeat procedure by the same physician) and 54 (surgical care only) may be applicable depending on the circumstances.Consult the most recent CPT guidelines for modifier usage.

Medical necessity for closed reduction of a TMJ dislocation is established when the patient experiences significant pain and dysfunction resulting from the dislocation.The procedure is necessary to restore normal jaw function and alleviate pain.

The clinical responsibility involves the physician's skill in manipulating the dislocated jaw back into place. This requires a thorough understanding of the anatomy of the temporomandibular joint and the application of appropriate manual techniques to achieve reduction. Post-reduction instructions to the patient regarding diet and jaw movement are also part of the responsibility.

IMPORTANT:If surgical intervention is required, use appropriate open treatment codes.If only evaluation and management services are performed, use the appropriate E&M codes.

In simple words: This code describes a doctor's treatment for a dislocated jaw. The doctor will manually move the jaw back into its proper place without surgery.This may include techniques like pulling on the jaw and repositioning the chin.

This CPT code (21480) encompasses the closed treatment of a temporomandibular joint (TMJ) dislocation, including the initial or subsequent reduction of the dislocation without surgical opening of the treatment site.The procedure involves manipulation to restore the mandibular condyle to its proper position within the glenoid fossa.It may be performed with or without the use of traction or other immobilization techniques. The code includes the necessary manipulation and any subsequent immobilization such as splinting, but excludes separately reported services like anesthesia, imaging, or the application of a cast or splint.

Example 1: A patient presents to the emergency department after a fall, experiencing significant pain and inability to close their mouth due to TMJ dislocation. The physician performs closed reduction under local anesthesia. , A patient with a history of TMJ disorders experiences a recurrent dislocation during a yawn.The physician performs a closed reduction in the office setting., An athlete sustains a TMJ dislocation during a sporting event. The physician performs closed reduction on the field, providing immediate pain relief and stabilization before transporting the patient to the hospital for further evaluation.

Detailed history of the injury mechanism, including the exact time of injury and events leading to the dislocation.Physician's documentation of the closed reduction technique used, assessment of reduction success (e.g., palpation, range of motion, improved jaw function), and post-reduction instructions to the patient.Imaging studies (if obtained).Any complications encountered or treated.

** Always refer to the most up-to-date CPT codebook and guidelines to ensure accurate coding and billing practices.Specific payer requirements and local coverage determinations may influence coding and reimbursement.

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