2025 CPT code 21175
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Head Surgery Feed
Reconstruction of the superior-lateral orbital rims and lower forehead, with or without grafts.
Modifiers 51 (multiple procedures), 59 (distinct procedural service), 76 (repeat procedure), and 62 (two surgeons) may be applicable depending on the circumstances of the procedure.
Medical necessity for this procedure is established by the presence of a significant craniofacial deformity that impacts the patient's physical appearance, function (vision), or overall health. Documentation should clearly demonstrate the need for surgical intervention based on the severity of the deformity and its impact on the patient.
The clinical responsibility includes pre-operative planning, surgical execution of the bifrontal craniotomy, orbital osteotomies (if needed), forehead advancement, bone grafting (including obtaining autografts if necessary), meticulous hemostasis, and closure of incisions. Post-operative care is also part of the clinical responsibility.
In simple words: This code describes a surgery to repair or reshape the bones around the eyes and forehead.The surgeon might use bone grafts from another part of the body to correct birth defects or injuries.
This CPT code encompasses the reconstruction of the superior-lateral orbital rims and lower forehead, addressing deformities such as plagiocephaly, trigonocephaly, or brachycephaly.The procedure may involve advancement or alteration of these structures, and may include bone grafting, encompassing the harvesting of autografts if necessary.A bifrontal craniotomy may be performed as part of this procedure. If performed for craniosynostosis, code 61557 should be used instead.
Example 1: A patient presents with severe plagiocephaly (flat head syndrome) requiring significant reshaping of the frontal and orbital bones.The surgeon performs a bifrontal craniotomy, advances the forehead, and uses autologous bone grafts from the iliac crest to achieve the desired correction., A patient sustains severe facial trauma in a motor vehicle accident, resulting in depressed frontal and orbital fractures.The surgeon performs a bifrontal craniotomy, elevates the depressed fragments, and uses titanium mesh for reinforcement., An infant is diagnosed with trigonocephaly (triangular-shaped forehead). The surgeon performs a bifrontal craniotomy, reshapes the frontal bone to correct the deformity, and uses a bone graft from the patient’s skull for aesthetic improvement.
* Preoperative imaging (CT scan, 3D imaging) to assess the extent of the deformity.* Intraoperative photographs documenting the surgical steps and the final result.* Detailed operative report outlining the surgical technique, including the type and amount of bone graft used, if any.* Postoperative imaging to evaluate the surgical outcome.* Patient history, including the nature and extent of the deformity, previous treatments, and relevant medical conditions.
** This procedure is complex and requires specialized surgical expertise.Always refer to the most current CPT codebook and coding guidelines for accurate billing.
- Revenue Code: P3D (MAJOR PROCEDURE, ORTHOPEDIC - OTHER)
- RVU: This information is not provided in the source data.Consult the current year's CPT codebook or a professional fee schedule for RVU information.
- Global Days : The global period for this procedure would need to be determined based on the specific services provided and the payer's guidelines.It is not explicitly defined within the source data.
- Payment Status: Active
- Modifier TC rule: The application of a technical component (TC) modifier is not applicable to this procedure.
- Fee Schedule : Historical fee schedule information is not available in the source data.Consult historical CPT codebooks or fee schedules for this information.
- Specialties:Plastic Surgery, Neurosurgery, Craniofacial Surgery, Oral and Maxillofacial Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center