2025 CPT code 21180
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Surgical Procedures on the Musculoskeletal System Surgery Feed
Reconstruction of the forehead and/or supraorbital rims using autograft.
Modifiers may be applicable depending on the specific circumstances of the procedure. Consult the CPT guidelines for appropriate modifier usage.
The medical necessity for this procedure is based on the presence of significant facial deformities that compromise facial aesthetics, function, or both.The severity of the deformity must be documented in the medical records.
The clinical responsibility involves the surgeon harvesting an autograft (bone graft) from a donor site (typically the hip), performing a craniotomy (incision of the skull), reshaping the forehead and supraorbital rims, using the autograft to fill in defects, and closing the incisions.
In simple words: The doctor rebuilds the forehead and/or the area above the eyes using a bone graft taken from another part of the patient's own body to fix serious facial deformities caused by injury, illness, or birth defects.
This CPT code describes the reconstruction of the entire or majority of the forehead and/or supraorbital rims using an autograft.The procedure includes obtaining the graft material from another location on the patient's body.It is used to correct significant facial deformities resulting from trauma, disease, or congenital conditions. The procedure involves harvesting the autograft, creating incisions on the forehead and supraorbital rims, dissecting to the subgaleal plane, performing a craniotomy, reshaping bony structures, filling defects with autograft material, and closing incisions with layered sutures.
Example 1: A patient presents with severe facial trauma resulting in a depressed frontal bone and significant orbital deformity. The surgeon uses 21180 to reconstruct the forehead and supraorbital rims using an autograft from the iliac crest., A patient with craniosynostosis requires surgery to reshape the skull and alleviate pressure on the brain. The surgeon utilizes 21180 to reconstruct the forehead and supraorbital rims using an autograft., A patient with a congenital deformity of the forehead and orbital region requires reconstruction to improve facial aesthetics and function. The surgeon utilizes 21180 for reconstruction with autograft material.
* Preoperative imaging (CT scan, MRI) demonstrating the deformity.* Operative report detailing the surgical technique, including the harvesting of the autograft and the reconstruction of the forehead and supraorbital rims.* Postoperative imaging to assess the outcome of the surgery.* Pathology report (if applicable) for any tissue removed.
** This code should not be used for procedures involving allografts or prosthetic materials; for such cases, code 21179 is appropriate.
- Revenue Code: P3D (MAJOR PROCEDURE, ORTHOPEDIC - OTHER)
- RVU: The relative value units (RVUs) for this code will vary based on geographic location, facility type, and other factors. Consult the CMS Physician Fee Schedule or other relevant payer guidelines for the most up-to-date information.
- Global Days : The global period for this procedure is not specified in the provided data.Additional resources should be consulted for clarification.
- Payment Status: Active
- Modifier TC rule: The applicability of a Technical Component (TC) modifier is not directly specified in the provided data and may depend on payer guidelines.
- Fee Schedule : The historical fee schedule is not available in the provided dataset.It is recommended to refer to external historical fee schedule data.
- Specialties:Plastic Surgery, Craniofacial Surgery, Neurosurgery, Oral and Maxillofacial Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Outpatient Hospital