Clinical Indicators: Le Fort Fracture

Approach Procedure	CPT	RBRVS Global Days
LeFort I, Treatment of palatal or maxillary fracture, with interdental wire fixation of denture or splint, closed	21421	90
LeFort I, Treatment of palatal or maxillary fracture, with interdental wire fixation of denture or splint, open	21422	90
LeFort I, Treatment of palatal or maxillary fracture, with interdental wire fixation of denture or splint, complicated, multiple approaches	21423	90
LeFort II, Closed treatment of nasomaxillary complex fracture with interdental wiring fixation or fixation of denture or splint	21345	90
LeFort II, Open with wiring and/or local fixation	21346	90
LeFort II, Open with wiring and/or local fixation, requiring multiple approaches	21347	90
LeFort II, Open with wiring and/or local fixation, multiple approaches with bone grafting	21348	90
LeFort III, Closed treatment of craniofacial separation using interdental wire fixation of denture or splint	21431	90
LeFort III, Open treatment of craniofacial separation, with wiring and/or internal fixation	21432	90
LeFort III, Open treatment of craniofacial separation, with wiring and/or internal fixation, complicated, multiple approaches	21433	90
LeFort III, Open treatment of craniofacial separation, with wiring and/or internal fixation, complicated, using internal and/or external fixation	21435	90
LeFort III, Open treatment of craniofacial separation, with wiring and/or internal fixation, complicated, multiple approaches, internal fixation with bone grafting	21436	90

Additional Approach Procedure	CPT	RBRVS Global Days
Tracheostomy, planned (separate procedure)	31600	0
Bone graft, any donor area; minor or small (e.g., dowel or button)	20900	90
Bone graft, any donor area; major or large	20902	90
Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)	20908	90
Cartilage graft; costochondral	20910	90
Graft; rib cartilage, autogeneous to face, chin, nose or ear (includes obtaining graft)	21230	90

History
1. Trauma, indicate mechanism of injury
2. Clear rhinorrhea
3. Visual problems
4. Malocclusion/dental status
5. Trismus
6. Facial numbness
7. Difficulty with sense of smell
Physical Examination
1. Nasal/oral bleeding
2. Oral/facial lacerations
3. Occlusal status (required)
4. Eye exam, vision and extraocular mobility
5. Airway compromise
6. Facial hypesthesia/anesthesia
7. Intracranial injury/mental status and Glasgow coma scale
8. Complete cranial nerve exam
9. Facial bony deformity or instability, especially the palate, nasal complex, and midface from the skull base
10. Otoscopic exam with attention to otorrhea
11. Gross hearing testing and tuning forks
12. Trismus
13. Anosmia/Hyposmia
14. Cerebral spinal rhinorrhea
Tests (as required)
1. Cervical spine radiographs (required)
2. CT scan/facial bones/head
  1. axial/coronal
3. Panorex if CT is not available to evaluate the mandible
4. Consultation with appropriate specialists with particular attention for ophthalmology and neurosurgery

Postoperative Observations

Adequate airway patency
Presence or absence of bleeding
Tolerable degree of pain/nausea
Evaluate sensory integrity especially in the V2 and V3 distribution
Document occlusal status
Wire cutters or scissors at bedside if appropriate
Monitor intake and output to detect inappropriate antidiuretic hormone syndrome.
Change in mental status
CSF leak (i.e., rhinorrhea, otorrhea)
Visual Status

Outcome Review

One Week
1. Incision healing well, including intraoral incisions
2. Evidence of infection
3. Fixation stable
4. Oral hygiene
5. Occlusal status
6. Extraocular movements
7. Nutritional status
8. Vision stable
9. Cerebral rhinorrhea
Beyond One Month
1. Nonunion/Malunion
2. Occlusal status
3. Oral-antral fistulas
4. Facial appearance/telecanthus/enophthalmos
5. Cerebral fluid rhinorrhea
6. Nutritional status
7. Nasal sinus complaints
8. Epiphora/dacrocystorhinitis
9. Anosmia/hyposmia
10. Facial hypesthesia/anesthesia
11. Vision status/diplopia
12. Persistent diplopia

Associated ICD-10-CM Diagnostic Codes (Representative, but not all-inclusive codes)

G69.0 Cerebrospinal fluid leak
S02.0XXA Fracture of vault of skull, initial encounter for closed fracture
S02.0XXB Fracture of vault of skull, initial encounter for open fracture
S02.0XXD Fracture of vault of skull, subsequent encounter for fracture with routine healing
S02.0XXG Fracture of vault of skull, subsequent encounter for fracture with delayed healing
S02.0XXK Fracture of vault of skull, subsequent encounter for fracture with nonunion
S02.0XXS Fracture of vault of skull, sequela
S06.330A Contusion and laceration of cerebrum, unspecified, without loss of consciousness, initial encounter
S06.330D Contusion and laceration of cerebrum, unspecified, without loss of consciousness, subsequent encounter
S06.330S Contusion and laceration of cerebrum, unspecified, without loss of consciousness, sequela
S06.310A Contusion and laceration of right cerebrum, without loss of consciousness, initial encounter
S06.310D Contusion and laceration of right cerebrum, without loss of consciousness, subsequent encounter
S06.310S Contusion and laceration of right cerebrum, without loss of consciousness, sequela
S06.320A Contusion and laceration of left cerebrum, without loss of consciousness, initial encounter
S06.320D Contusion and laceration of left cerebrum, without loss of consciousness, subsequent encounter
S06.320S Contusion and laceration of left cerebrum, without loss of consciousness, sequela
S06.4X0A Epidural hemorrhage without loss of consciousness, initial encounter
S06.4X0D Epidural hemorrhage without loss of consciousness, subsequent encounter
S06.4X0S Epidural hemorrhage without loss of consciousness, sequela
S06.5X0A Traumatic subdural hemorrhage without loss of consciousness, initial encounter
S06.5X0D Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter
S06.5X0S Traumatic subdural hemorrhage without loss of consciousness, sequela
S06.6X0A Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter
S06.6X0D Traumatic subarachnoid hemorrhage without loss of consciousness, subsequent encounter
S06.6X0S Traumatic subarachnoid hemorrhage without loss of consciousness, sequela
S06.360A Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, initial encounter
S06.360D Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, subsequent encounter
S06.360S Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, sequela
S06.890A Other specified intracranial injury without loss of consciousness, initial encounter
S06.890D Other specified intracranial injury without loss of consciousness, subsequent encounter
S06.890S Other specified intracranial injury without loss of consciousness, sequela
S06.9X0A Unspecified intracranial injury without loss of consciousness, initial encounter
S06.9X0D Unspecified intracranial injury without loss of consciousness, subsequent encounter
S06.9X0S Unspecified intracranial injury without loss of consciousness, sequela
S02.10XA Unspecified fracture of base of skull, initial encounter for closed fracture
S02.10XD Unspecified fracture of base of skull, subsequent encounter for fracture with routine healing
S02.10XG Unspecified fracture of base of skull, subsequent encounter for fracture with delayed healing
S02.10XK Unspecified fracture of base of skull, subsequent encounter for fracture with nonunion
S02.10XS Unspecified fracture of base of skull, sequela
S02.110AType I occipital condyle fracture, initial encounter for closed fracture
S02.110D Type I occipital condyle fracture, subsequent encounter for fracture with routine healing
S02.110G Type I occipital condyle fracture, subsequent encounter for fracture with delayed healing
S02.110K Type I occipital condyle fracture, subsequent encounter for fracture with nonunion
S02.110S Type I occipital condyle fracture, sequela
S02.111A Type II occipital condyle fracture, initial encounter for closed fracture
S02.111D Type II occipital condyle fracture, subsequent encounter for fracture with routine healing
S02.111G Type II occipital condyle fracture, subsequent encounter for fracture with delayed healing
S02.111K Type II occipital condyle fracture, subsequent encounter for fracture with nonunion
S02.111S Type II occipital condyle fracture, sequela
S02.112A Type III occipital condyle fracture, initial encounter for closed fracture
S02.112D Type III occipital condyle fracture, subsequent encounter for fracture with routine healing
S02.112G Type III occipital condyle fracture, subsequent encounter for fracture with delayed healing
S02.112K Type III occipital condyle fracture, subsequent encounter for fracture with nonunion
S02.112S Type III occipital condyle fracture, sequela
S02.113A Unspecified occipital condyle fracture, initial encounter for closed fracture
S02.113D Unspecified occipital condyle fracture, subsequent encounter for fracture with routine healing
S02.113G Unspecified occipital condyle fracture, subsequent encounter for fracture with delayed healing
S02.113K Unspecified occipital condyle fracture, subsequent encounter for fracture with nonunion
S02.113S Unspecified occipital condyle fracture, sequela
S02.118A Other fracture or occiput, initial encounter for closed fracture
S02.118D Other fracture or occiput, subsequent encounter for fracture with routine healing
S02.118G Other fracture or occiput, subsequent encounter for fracture with delayed healing
S02.118K Other fracture or occiput, subsequent encounter for fracture with nonunion
S02.118S Other fracture or occiput, sequela
S02.119S Unspecified fracture of occiput, initial encounter for closed fracture
S02.119S Unspecified fracture of occiput, subsequent encounter for fracture with routine healing
S02.119S Unspecified fracture of occiput, subsequent encounter for fracture with delayed healing
S02.119S Unspecified fracture of occiput, subsequent encounter for fracture with nonunion
S02.119S Unspecified fracture of occiput, sequela
S02.19XA Other fracture of base of skull, initial encounter for closed fracture
S02.19XD Other fracture of base of skull, subsequent encounter for fracture with routine healing
S02.19XG Other fracture of base of skull, subsequent encounter for fracture with delayed healing
S02.19XK Other fracture of base of skull, subsequent encounter for fracture with nonunion
S02.19XS Other fracture of base of skull, sequela
S02.400A Malar fracture unspecified, initial encounter for closed fracture
S02.400B Malar fracture unspecified, initial encounter for open fracture
S02.400D Malar fracture unspecified, subsequent encounter for fracture with routine healing
S02.400G Malar fracture unspecified, subsequent encounter for fracture with delayed healing
S02.400K Malar fracture unspecified, subsequent encounter for fracture with nonunion
S02.400S Malar fracture unspecified, sequela
S02.401A Maxillary fracture, unspecified, initial encounter for closed fracture
S02.401B Maxillary fracture, unspecified, initial encounter for open fracture
S02.401D Maxillary fracture, unspecified, subsequent encounter for fracture with routine healing
S02.401G Maxillary fracture, unspecified, subsequent encounter for fracture with delayed healing
S02.401K Maxillary fracture, unspecified, subsequent encounter for fracture with nonunion
S02.401S Maxillary fracture, unspecified, sequela
S02.402A Zygomatic fracture, unspecified, initial encounter for closed fracture
S02.402B Zygomatic fracture, unspecified, initial encounter for open fracture
S02.402D Zygomatic fracture, unspecified, subsequent encounter for fracture with routine healing
S02.402G Zygomatic fracture, unspecified, subsequent encounter for fracture with delayed healing
S02.402K Zygomatic fracture, unspecified, subsequent encounter for fracture with nonunion
S02.402S Zygomatic fracture, unspecified, sequela
S02.411A LeFort I fracture, initial encounter for closed fracture
S02.411B LeFort I fracture, initial encounter for open fracture
S02.411D LeFort I fracture, subsequent encounter for fracture with routine healing
S02.411G LeFort I fracture, subsequent encounter for fracture with delayed healing
S02.411K LeFort I fracture, subsequent encounter for fracture with nonunion
S02.411S LeFort I fracture, sequela
S02.412A LeFort II fracture, initial encounter for closed fracture
S02.412B LeFort II fracture, initial encounter for open fracture
S02.412D LeFort II fracture, subsequent encounter for fracture with routine healing
S02.412G LeFort II fracture, subsequent encounter for fracture with delayed healing
S02.412K LeFort II fracture, subsequent encounter for fracture with nonunion
S02.412S LeFort II fracture, sequela
S02.413A LeFort III fracture, initial encounter for closed fracture
S02.413B LeFort III fracture, initial encounter for open fracture
S02.413D LeFort III fracture, subsequent encounter for fracture with routine healing
S02.413G LeFort III fracture, subsequent encounter for fracture with delayed healing
S02.413K LeFort III fracture, subsequent encounter for fracture with nonunion
S02.413S LeFort III fracture, sequela
S02.42XA Fracture of alveolus of maxilla, initial encounter for closed fracture
S02.42XB Fracture of alveolus of maxilla, initial encounter for open fracture
S02.42XD Fracture of alveolus of maxilla, subsequent encounter for fracture with routine healing
S02.42XG Fracture of alveolus of maxilla, subsequent encounter for fracture with delayed healing
S02.42XK Fracture of alveolus of maxilla, subsequent encounter for fracture with nonunion
S02.42XS Fracture of alveolus of maxilla, sequela
S02.3XXA Fracture of orbital floor, initial encounter for closed fracture
S02.3XXB Fracture of orbital floor, initial encounter for open fracture
S02.3XXD Fracture of orbital floor, subsequent encounter for fracture with routine healing
S02.3XXG Fracture of orbital floor, subsequent encounter for fracture with delayed healing
S02.3XXK Fracture of orbital floor, subsequent encounter for fracture with nonunion
S02.3XXS Fracture of orbital floor, sequela
S02.8XXA Fractures of other specified skull and facial bones, initial encounter for closed fracture
S02.8XXB Fractures of other specified skull and facial bones, initial encounter for open fracture
S02.8XXD Fractures of other specified skull and facial bones, subsequent encounter for fracture with routine healing
S02.8XXG Fractures of other specified skull and facial bones, subsequent encounter for fracture with delayed healing
S02.8XXK Fractures of other specified skull and facial bones, subsequent encounter for fracture with nonunion
S02.8XXS Fractures of other specified skull and facial bones, sequela
S02.92XA Unspecified fracture of facial bones, initial encounter for closed fracture
S02.92XB Unspecified fracture of facial bones, initial encounter for open fracture
S02.92XD Unspecified fracture of facial bones, subsequent encounter for fracture with routine healing
S02.92XG Unspecified fracture of facial bones, subsequent encounter for fracture with delayed healing
S02.92XK Unspecified fracture of facial bones, subsequent encounter for fracture with nonunion
S02.92XS Unspecified fracture of facial bones, sequela
S02.91XA Unspecified fracture of skull, initial encounter for closed fracture
S02.91XD Unspecified fracture of skull, subsequent encounter for fracture with routine healing
S02.91XG Unspecified fracture of skull, subsequent encounter for fracture with delayed healing
S02.91XK Unspecified fracture of skull, subsequent encounter for fracture with nonunion
S02.91XS Unspecified fracture of skull, sequela
S02.2XXS Fracture of nasal bones, sequela
S02.5XXS Fracture of tooth (traumatic), sequela
S02.600S Fracture of unspecified part of body of mandible, sequela
S02.609S Fracture of mandible, unspecified, sequela
S02.61XS Fracture of condylar process of mandible, sequela
S02.62XS Fracture of subcondylar process of mandible, sequela
S02.63XS Fracture of coronoid process of mandible, sequela
S02.64XS Fracture of ramus of mandible, sequela
S02.65XS Fracture of angle of mandible, sequela
S02.66XS Fracture of symphysis of mandible, sequela
S02.67XS Fracture of alveolus of mandible, sequela
S02.69XS Fracture of mandible of other specified site, sequela
R13.0 Aphagia
R13.10 Dysphagia, unspecified
R13.11 Dysphagia, oral phase
R13.12 Dysphagia, oropharyngeal phase
R13.13 Dysphagia, pharyngeal phase
R13.14 Dysphagia, pharyngoesophageal phase
R13.19 Other dysphagia
S06.311A Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, initial encounter
S06.311D Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes or less, subsequent encounter
S06.311S Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, sequela
S06.312A Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.312D Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.312S Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.313A Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.313D Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.313S Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.314A Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.314D Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.314S Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, sequela
S06.315A Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.315D Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
S06.315S Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06.316A Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.316D Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.316S Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
S06.317A Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.317D Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter
S06.317S Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela
S06.318A Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.318D Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter
S06.318S Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela
S06.319A Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, initial encounter
S06.319D Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, subsequent encounter
S06.319S Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, sequela
S06.321A Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less, initial encounter
S06.321D Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes or less, subsequent encounter
S06.321S Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less, sequela
S06.322A Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.322D Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.322S Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.323A Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.323D Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.323S Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.324A Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.324D Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.324S Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours, sequela
S06.325A Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.325D Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
S06.325S Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06.326A Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.326D Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.326S Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
S06.327A Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.327D Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter
S06.327S Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela
S06.328A Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.328D Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter
S06.328S Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela
S06.329A Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, initial encounter
S06.329D Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, subsequent encounter
S06.329S Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, sequela
S06.331A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial encounter
S06.331D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes or less, subsequent encounter
S06.331S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, sequela
S06.332A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.332D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.332S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.333A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.333D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.333S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.334A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.334D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.334S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, sequela
S06.335A Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.335D Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
S06.335S Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06.336A Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.336D Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.336S Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
S06.337A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.337D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter
S06.337S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela
S06.338A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.338D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter
S06.338S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela
S06.339A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter
S06.339D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, subsequent encounter
S06.339S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, sequela
S06.340A Traumatic hemorrhage of right cerebrum without loss of consciousness, initial encounter
S06.340D Traumatic hemorrhage of right cerebrum without loss of consciousness, subsequent encounter
S06.340S Traumatic hemorrhage of right cerebrum without loss of consciousness, sequela
S06.341A Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, initial encounter
S06.341D Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, subsequent encounter
S06.341S Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, sequela
S06.342A Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.342D Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.342S Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.343A Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.343D Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.343S Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.344A Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.344D Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.344S Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, sequela
S06.345A Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.345D Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
S06.345S Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06.346A Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.346D Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.346S Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
S06.347A Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.347D Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter
S06.347S Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela
S06.348A Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.348D Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter
S06.348S Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela
S06.349A Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, initial encounter
S06.349D Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, subsequent encounter
S06.349S Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, sequela
S06.350A Traumatic hemorrhage of left cerebrum without loss of consciousness, initial encounter S06.350D Traumatic hemorrhage of left cerebrum without loss of consciousness, subsequent encounter
S06.350S Traumatic hemorrhage of left cerebrum without loss of consciousness, sequela
S06.351A Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, initial encounter
S06.351D Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less,
subsequent encounter
S06.351S Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, sequela
S06.352A Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.352D Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.352S Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.353A Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.353D Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.353S Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.354A Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.354D Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.354S Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, sequela
S06.355A Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.355D Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
S06.355S Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06.356A Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.356D Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.356S Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
S06.357A Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.357D Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter
S06.357S Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela
S06.358A Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.358D Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter
S06.358S Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela
S06.359A Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, initial encounter
S06.359D Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, subsequent encounter
S06.359S Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, sequela
S06.361A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial encounter
S06.361D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, subsequent encounter
S06.361S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, sequela
S06.362A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.362D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.362S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.363A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.363D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.363S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.364A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.364D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.364S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, sequela
S06.365A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.365D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
S06.365S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06.366A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.366D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.366S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
S06.367A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.367D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter
S06.367S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela
S06.368A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.368D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter
S06.368S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela
S06.369A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter
S06.369D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, subsequent encounter
S06.369S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, sequela
S06.891A Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.891D Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.891S Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.892A Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.892D Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.892S Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.893A Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.893D Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.893S Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.894A Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.894D Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.894S Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, sequela
S06.895A Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.895D Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter
S06.895S Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela
S06.896A Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.896D Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.896S Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
S06.897A Other specified intracranial injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.897D Other specified intracranial injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter
S06.897S Other specified intracranial injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela
S06.898A Other specified intracranial injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.898D Other specified intracranial injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter
S06.898S Other specified intracranial injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela
S06.899A Other specified intracranial injury with loss of consciousness of unspecified duration, initial encounter
S06.899D Other specified intracranial injury with loss of consciousness of unspecified duration, subsequent encounter
S06.899S Other specified intracranial injury with loss of consciousness of unspecified duration, sequela
S06.9X1A Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.9X1D Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.9X1S Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.9X2A Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter
S06.9X2D Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.9X2S Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.9X3A Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
S06.9X3D Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter
S06.9X3S Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.9X4A Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.9X4D Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.9X4S Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, sequela
S06.9X5A Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to preexisting conscious level, initial encounter
S06.9X5D Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to preexisting conscious level, subsequent encounter
S06.9X5S Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to preexisting conscious level, sequela
S06.9X6A Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.9X6D Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter
S06.9X6S Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela
S06.9X7A Unspecified intracranial injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.9X7D Unspecified intracranial injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter
S06.9X7S Unspecified intracranial injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela
S06.9X8A Unspecified intracranial injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.9X8D Unspecified intracranial injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter
S06.9X8S Unspecified intracranial injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela
S06.9X9A Unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter
S06.9X9D Unspecified intracranial injury with loss of consciousness of unspecified duration, subsequent encounter
S06.9X9S Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela

Additional Information

Assistant Surgeon—Code dependent
Supply Charges—N
Prior Approval—N
Anesthesia Code(s) — 00190

Patient Information

A LeFort fracture is a fracture of the midface bone, cheek bones, and the bones under the eye. These fractures may occur alone or in combination with fractures of the jaw. Injuries to the eyes or brain are common. Treatment goals are to obtain proper alignment of teeth and restoration of midface or nasal appearance, including length and projection. Treatment includes wiring or plating of bone fragments and the wiring of the upper and lower teeth together. The risk of airway compromise may require the establishment of a breathing passage in the neck (tracheostomy). Complications include bleeding, infection, poor alignment of the teeth, difficulty breathing, excess tearing, a change in vision or double vision, decreased or lack of sense of smell, recurrent sinus infections, numbness of face, increased distance between the eyes, drainage of spinal fluid through the nose or ear, and nonhealing or assymetric healing of facial bones along the fracture line.

Important Disclaimer Notice (Updated 8/7/14)

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care. The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical indicators will not ensure successful treatment in every situation. The AAO-HNS/F emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual physicians. Clinical indicators are not intended to and should not be treated as legal, medical, or business advice.

CPT five-digit codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Updated January 2015

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