2025 CPT code 21490
(Active) Effective Date: N/A Revision Date: N/A Surgery - Fracture and/or Dislocation Treatment Musculoskeletal System Feed
Open treatment of temporomandibular dislocation.
Modifiers may apply depending on the circumstances of the procedure. For example, modifier 54 (surgical care only) may be used if the physician providing the initial treatment will not be providing subsequent treatment. Modifier 76 (repeat procedure or service by the same physician) can be appended if a subsequent re-reduction is performed.
Medical necessity for open treatment of a temporomandibular dislocation is established when conservative measures (e.g., manipulation under anesthesia) fail to reduce the dislocation, or when there are complications such as significant joint damage, fracture, or entrapment of soft tissues requiring surgical intervention. The decision to proceed with an open reduction is based on clinical judgment and should be well documented.
The physician or other qualified healthcare professional is responsible for performing the surgical procedure, including making the incision, visualizing and manipulating the joint, removing loose cartilage, irrigating the wound, and closing the incision. Pre-operative and post-operative care may be billed separately using appropriate EM codes.
In simple words: The doctor surgically fixes a dislocated jaw. This involves an incision to access the jaw joint, repositioning the joint, cleaning any loose pieces of cartilage, and closing the incision.
Open treatment of temporomandibular dislocation involves surgical access to the temporomandibular joint (TMJ) to reduce the dislocation.This procedure may include an incision along the zygomatic process, visualization of the joint, division of the joint capsule, removal of any loose cartilage, and manipulation of the joint back into its proper position.Wound irrigation and closure are also included.
Example 1: A patient presents to the emergency room after a motor vehicle accident with a severely dislocated jaw. The patient is unable to close their mouth and is in significant pain.Open reduction of the TMJ is performed., A patient with a history of TMJ disorders experiences a sudden dislocation of the jaw.Conservative measures fail to reduce the dislocation, requiring open surgical intervention., During orthognathic surgery (jaw surgery to correct irregularities in jaw alignment), an unexpected TMJ dislocation occurs. Open reduction is necessary to restore proper jaw alignment and function.
* Detailed history and physical examination documenting the dislocation.* Operative report specifying the surgical approach, techniques used, findings during the procedure (e.g., presence of loose cartilage), and the restoration of proper joint alignment.* Anesthesia records.* Pathology reports (if any tissue samples were taken).* Postoperative progress notes documenting the patient's recovery and any complications.* Imaging studies (e.g., X-rays, CT scans) before and after the procedure.
** This code should only be used when the TMJ dislocation requires open surgical treatment.Conservative measures should be documented prior to resorting to open reduction.
- Revenue Code: P5B (AMBULATORY PROCEDURES - MUSCULOSKELETAL)
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Oral and Maxillofacial Surgery, Plastic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Office