DEPUY SYNTHES 2021 TRUMATCH - PHYSICIAN AND FACILITY
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DePuy Synthes 2021 TRUMATCH® CMF Personalized Solutions Reimbursement Guide Physician and Facility
Contents
This guide has been developed to assist physicians and facilities in coding for the use of the TRUMATCH® CMF
Personalized Solutions for facial reconstruction, orthognathic surgery, distraction and cranial reconstruction
procedures.
These procedures may be a covered service if they meet all of the requirements established by Medicare and private
payers. It is essential that each claim be coded properly and supported with appropriate documentation in the
medical record.
Physician Services 3
• CPT® Codes
Facility Services 6
Outpatient Services
• Ambulatory Payment Classifications (APCs)
• Ambulatory Surgery Center (ASC) Payment Groups
Inpatient Services
• Medicare Severity Diagnosis Related Groups (MS-DRGs)
Procedure Codes 10
• ICD-10-PCS
Diagnosis Codes 13
• ICD-10-CM
HCPCS Codes and Revenue Codes 19
Modifiers 20
FOR ADDITIONAL QUESTIONS OR INFORMATION CONTACT
DePuy Synthes Reimbursement Support Services
800-410-8177
DePuySynthes@avaniareimbursement.com
Disclaimer
THE INFORMATION CONTAINED IN THIS DOCUMENT IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENTS NO STATEMENT,
PROMISE, OR GUARANTEE BY DEPUY SYNTHES CONCERNING LEVELS OF REIMBURSEMENT, PAYMENT, OR CHARGE. SIMILARLY, ALL CPT
[COPYRIGHT AMA] AND HCPCS CODES ARE SUPPLIED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENT NO STATEMENT, PROMISE, OR
GUARANTEE BY DEPUY SYNTHES THAT THESE CODES WILL BE APPROPRIATE OR THAT REIMBURSEMENT WILL BE MADE. IT IS NOT INTENDED TO
INCREASE OR MAXIMIZE REIMBURSEMENT BY ANY PAYOR. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PAYOR ORGANIZATION
WITH REGARD TO ITS REIMBURSEMENT POLICIES.
2021 Reimbursement Guide DePuy Synthes 2Physician Services
Current Procedural Terminology (CPT®) codes and Medicare Physician Fee Schedule values for procedures involving
the use of TRUMATCH® CMF Personalized Solutions are indicated below.
TRUMATCH® CMF Personalized Solutions is comprised of pre-operative planning services, patient specific surgical
guides and anatomical bone models for transferring the preoperative plan to the operating room. The planning
services and products are available for facial reconstruction, orthognathic surgery, distraction and cranial
reconstruction.
Use of physician pre-operative planning services for surgical procedures is considered to be inclusive in the primary
procedural CPT® code. Outlined below are CPT® codes that may be applicable when reporting the use of TRUMATCH®
CMF Personalized Solutions for facial reconstruction, orthognathic surgery, distraction and cranial reconstruction
procedures.
Mandible Reconstruction
2021
2021
CPT® Code Description Medicare National
Total RVUs
Average Payment
Excision of benign tumor or cyst of mandible, by enucleation and/or
21040 10.96 $382
curettage
21044 Excision of malignant tumor of mandible 25.22 $880
21045 Excision of malignant tumor of mandible; radical resection 35.03 $1,222
Excision of benign tumor or cyst of mandible; requiring intra-oral
21046 29.79 $1,039
osteotomy (eg, locally aggressive or destructive lesion[s])
Excision of benign tumor or cyst of mandible; requiring extra-oral
21047 osteotomy and partial mandibulectomy (eg, locally aggressive or 37.00 $1,291
destructive lesion[s])
Reconstruction midface, osteotomies (other than LeFort type) and bone
21188 47.17 $1,646
grafts (includes obtaining autografts)
Reconstruction of mandibular rami, horizontal, vertical, C, or L
21193 36.19 $1,263
osteotomy; without bone graft
Reconstruction of mandibular rami, horizontal, vertical, C, or L
21194 41.83 $1,460
osteotomy; with bone graft (includes obtaining graft)
Reconstruction of mandibular rami and/or body, sagittal split; without
21195 40.11 $1,400
internal rigid fixation
Reconstruction of mandibular rami and/or body, sagittal split; with
21196 41.07 $1,433
internal rigid fixation
21198 Osteotomy, mandible, segmental 31.51 $1,099
21199 Osteotomy, mandible, segmental; with genioglossus advancement 29.97 $1,046
21215 Graft, bone; mandible (includes obtaining graft) 23.29 $813
Reconstruction of mandibular condyle with bone and cartilage
21247 46.43 $1,620
autografts (includes obtaining grafts) (eg, for hemifacial microsomia)
1
https://www.jnjmedicaldevices.com/en-US/product/trumatchr-cmf-personalized-solutions
2021 Reimbursement Guide DePuy Synthes 3Midface Reconstruction
2021
2021
CPT® Code Description Medicare National
Total RVUs
Average Payment
21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) 29.28 $1,022
21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) 22.45 $783
Distraction Osteogensis
2021
2021
CPT® Code Description Medicare National
Total RVUs
Average Payment
Application of a uniplane (pins or wires in 1 plane), unilateral, external
20690 17.57 $613
fixation system
Application of a multiplane (pins or wires in more than 1 plane),
20692 32.90 $1,148
unilateral, external fixation system eg, Ilizarov, Monticelli type)
Adjustment or revision of external fixation system requiring anesthesia
20693 13.04 $455
(eg, new pin[s] or wire[s] and/or new ring[s] or bar[s])
20694 Removal, under anesthesia, of external fixation system 9.98 $348
Cranial Reconstruction
2021
2021
CPT® Code Description Medicare National
Total RVUs
Average Payment
Reconstruction, entire or majority of forehead and/or supraorbital rims;
21179 44.75 $1,561
with grafts (allograft or prosthetic material)
Reconstruction, entire or majority of forehead and/or supraorbital rims;
21180 49.99 $1,744
with autografts (includes obtaining grafts)
62140 Cranioplasty for skull defect; up to 5 cm diameter 30.03 $1,048
62141 Cranioplasty for skull defect; larger than 5 cm diameter 33.76 $1,178
62143 Replacement of bone flap or prosthetic plate of skull 30.89 $1,078
Crainoplasty with autograft (includes obtaining bone grafts); up to 5 cm
62146 36.92 $1,288
diameter
Crainoplasty with autograft (includes obtaining bone grafts); larger than
62147 42.87 $1,461
5 cm diameter
Incision and retrieval of subcutaneous cranial bone graft for crainoplasty
+62148 3.70 $129
(List separately in addition to code for primary procedure)
Orthognathic Surgery
2021
2021
CPT® Code Description Medicare National
Total RVUs
Average Payment
21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) 15.47 $540
21121 Genioplasty; sliding osteotomy, single piece 16.06 $560
Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge
21122 22.66 $791
excision or bone wedge reversal for asymmetrical chin)
2021 Reimbursement Guide DePuy Synthes 4Genioplasty; sliding, augmentation with interpositional bone grafts
21123 25.63 $894
(includes obtaining autografts)
Reconstruction midface, LeFort I; single piece, segment movement in any
21141 39.11 $1,365
direction (eg, for Long Face Syndrome),without bone graft
Reconstruction midface, LeFort I; 2 pieces, segment movement in any
21142 40.16 $1,401
direction, without bone graft
Reconstruction midface, LeFort I; 3 or more pieces, segment movement
21143 41.56 $1,450
in any direction, without bone graft
Reconstruction midface, LeFort I; single piece, segment movement in any
21145 45.52 $1,588
direction, requiring bone grafts (includes obtaining autografts)
Reconstruction midface, LeFort I; 2 pieces, segment movement in any
21146 direction, requiring bone grafts (includes obtaining autografts) (eg, 47.51 $1,658
ungrafted unilateral alveolar cleft)
Reconstruction midface, LeFort I; 3 or more pieces, segment movement
21147 in any direction, requiring bone grafts (includes obtaining autografts) 50.04 $1,746
(eg, ungrafted bilateral alveolar cleft or multiple osteotomies)
Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins
21150 48.22 $1,683
Syndrome)
Reconstruction midface, LeFort II; any direction, requiring bone grafts
21151 53.05 $1,851
(includes obtaining autografts)
Reconstruction midface, LeFort III (extracranial), any type, requiring bone
21154 57.05 $1,991
grafts (includes obtaining autografts); without LeFort I
Reconstruction midface, LeFort III (extracranial), any type, requiring bone
21155 63.22 $2,206
grafts (includes obtaining autografts); with LeFort I
Reconstruction of mandibular rami, horizontal, vertical, C, or L
21193 36.19 $1,263
osteotomy; without bone graft
Reconstruction of mandibular rami, horizontal, vertical, C, or L
21194 41.83 $1,460
osteotomy; with bone graft (includes obtaining graft)
Reconstruction of mandibular rami and/or body, sagittal split; without
21195 40.11 $1,400
internal rigid fixation
Reconstruction of mandibular rami and/or body, sagittal split; with
21196 41.07 $1,433
internal rigid fixation
2021 Reimbursement Guide DePuy Synthes 5Facility Services
Outpatient Services
Medicare reimburses outpatient hospital and Ambulatory Surgery Center (ASC) services under the Outpatient
Prospective Payment System (OPPS), which bases payment on Ambulatory Payment Classifications (APCs) and ASC
Payment Groups. Services are reported with CPT® codes. The Medicare national average payments for TRUMATCH®
CMF Personalized Solutions for facial reconstruction, orthognathic surgery, distraction and cranial reconstruction
procedures in the outpatient setting are listed below.
Mandible Reconstruction
Ambulatory Surgical
Hospital Outpatient
Center
2021 2021
CPT® Code Description SI APC Medicare National PI Medicare National
Average Payment Average Payment
Excision of benign tumor or cyst of
21040 J1 5164 $2,736 A2 $1088
mandible, by enucleation and/or curettage
21044 Excision of malignant tumor of mandible J1 5165 $5,086 A2 $2,399
Excision of benign tumor or cyst of
mandible; requiring intra-oral osteotomy
21046 J1 5165 $5,086 A2 $2,399
(eg, locally aggressive or destructive
lesion[s])
Excision of benign tumor or cyst of
mandible; requiring extra-oral osteotomy
21047 J1 5165 $5,086 A2 $2,399
and partial mandibulectomy (eg, locally
aggressive or destructive lesion[s])
Reconstruction midface, osteotomies
21188 (other than LeFort type) and bone grafts J1 5165 $5,086 N/A N/A
(includes obtaining autografts)
Reconstruction of mandibular rami,
21193 horizontal, vertical, C, or L osteotomy; J1 5165 $5,086 G2 $2,399
without bone graft
Reconstruction of mandibular rami,
21194 horizontal, vertical, C, or L osteotomy; J1 5165 $5,086 N/A N/A
with bone graft (includes obtaining graft)
Reconstruction of mandibular rami and/or
21195 body, sagittal split; without internal rigid J1 5165 $5,086 J8 $3,604
fixation
21198 Osteotomy, mandible, segmental J1 5165 $5,086 G2 $2,399
Osteotomy, mandible, segmental; with
21199 J1 5165 $5,086 G2 $2,399
genioglossus advancement
Graft, bone; mandible (includes obtaining
21215 J1 5165 $5,086 A2 $2,399
graft)
Reconstruction of mandibular condyle
with bone and cartilage autografts
21247 J1 5165 $5,086 N/A N/A
(includes obtaining grafts) (eg, for
hemifacial microsomia)
2021 Reimbursement Guide DePuy Synthes 6Midface Reconstruction
Ambulatory Surgical
Hospital Outpatient
Center
2021 2021
CPT® Code Description SI APC Medicare National PI Medicare National
Average Payment Average Payment
Osteotomy, maxilla, segmental (eg,
21206 J1 5165 $5,086 A2 $2,399
Wassmund or Schuchard)
Graft, bone; nasal, maxillary or malar
21210 J1 5165 $5,086 A2 $2,399
areas (includes obtaining graft)
Distraction Osteogenesis
Ambulatory Surgical
Hospital Outpatient
Center
2021 2021
CPT® Code Description SI APC Medicare National PI Medicare National
Average Payment Average Payment
Application of a uniplane (pins or wires in
20690 1 plane), unilateral, external fixation J1 5114 $6,265 J8 $4,194
system
Application of a multiplane (pins or wires
in more than 1 plane), unilateral, external
20692 J1 5115 $12,315 J8 $9,112
fixation system (eg, Ilizarov, Monticelli
type)
Adjustment or revision of external fixation
system requiring anesthesia (eg, new
20693 J1 5114 $6,265 A2 $2,944
pin[s] or wire[s] and/or new ring[s] or
bar[s])
Removal, under anesthesia, of external
20694 Q2 5112 $1,392 A2 $727
fixation system
Cranial Reconstruction
Ambulatory Surgical
Hospital Outpatient
Center
2021 2021
CPT® Code Description SI APC Medicare National PI Medicare National
Average Payment Average Payment
Reconstruction, entire or majority of
21179 forehead and/or supraorbital rims; with J1 5165 $5,086 N/A N/A
grafts (allograft or prosthetic material)
Reconstruction, entire or majority of
21180 forehead and/or supraorbital rims; with J1 5165 $5,086 N/A N/A
autografts (includes obtaining grafts)
Orthognathic Surgery
Ambulatory Surgical
Hospital Outpatient
Center
2021 2021
CPT® Code Description SI APC Medicare National PI Medicare National
Average Payment Average Payment
Genioplasty; augmentation (autograft,
21120 J1 5165 $5,086 G2 $2,399
allograft, prosthetic material)
Genioplasty; sliding osteotomy, single
21121 J1 5164 $2,736 A2 $1,088
piece
2021 Reimbursement Guide DePuy Synthes 7Genioplasty; sliding osteotomies, 2 or
more osteotomies (eg, wedge excision or
21122 J1 5165 $5,086 A2 $2,399
bone wedge reversal for asymmetrical
chin)
Genioplasty; sliding, augmentation with
21123 interpositional bone grafts (includes J1 5164 $2,736 A2 $1,088
obtaining autografts)
Reconstruction midface, LeFort I; single
piece, segment movement in any
21141 J1 5165 $5,086 A2 $1,088
direction (eg, for Long Face
Syndrome),without bone graft
Reconstruction midface, LeFort I; 2 pieces,
21142 segment movement in any direction, J1 5165 $5,086 N/A N/A
without bone graft
Reconstruction midface, LeFort I; 3 or
21143 more pieces, segment movement in any J1 5165 $5,086 N/A N/A
direction, without bone graft
Reconstruction midface, LeFort I; single
piece, segment movement in any
21145 J1 5165 $5,086 N/A N/A
direction, requiring bone grafts (includes
obtaining autografts)
Reconstruction midface, LeFort I; single
piece, segment movement in any
21146 J1 5165 $5,086 N/A N/A
direction, requiring bone grafts (includes
obtaining autografts)
Reconstruction midface, LeFort II; anterior
21150 J1 5165 $5,086 G2 $2,399
intrusion (eg, Treacher-Collins Syndrome)
Reconstruction midface, LeFort II; any
21151 direction, requiring bone grafts (includes J1 5165 $5,086 N/A N/A
obtaining autografts)
Reconstruction midface, LeFort III
(extracranial), any type, requiring bone
21154 J1 5165 $5,086 N/A N/A
grafts (includes obtaining autografts);
without LeFort I
Reconstruction of mandibular rami,
21193 horizontal, vertical, C, or L osteotomy; J1 5165 $5,086 G2 $2,399
without bone graft
Reconstruction of mandibular rami,
21194 horizontal, vertical, C, or L osteotomy; J1 5165 $5,086 N/A N/A
with bone graft (includes obtaining graft)
Reconstruction of mandibular rami and/or
21195 body, sagittal split; without internal rigid J1 5165 $5,086 J8 $3,604
fixation
Reconstruction of mandibular rami and/or
21196 body, sagittal split; with internal rigid J1 5165 $5,086 N/A N/A
fixation
2021 Reimbursement Guide DePuy Synthes 8Hospital Inpatient Services
Medicare reimburses inpatient hospital services under the Inpatient Prospective Payment System (IPPS), which bases
payment on MS-DRGs (Medicare Severity Diagnosis Related Groups). The MS-DRGs and Medicare national average
payments for TRUMATCH® CMF Personalized Solutions for facial reconstruction, orthognathic surgery, distraction
and cranial reconstruction procedures are provided below:
2021 2021
MS-DRG Description Relative Medicare National
Weight Average Payment
140 Major Head and Neck Procedures with MCC 3.9806 $25,585
141 Major Head and Neck Procedures with CC 2.2075 $14,889
142 Major Head and Neck Procedures without CC/MCC 1.6088 $10,341
Other Musculoskeletal System and Connective Tissue O.R. Procedures
515 3.1370 $20,163
with MCC
Other Musculoskeletal System and Connective Tissue O.R. Procedures
516 1.9611 $12,605
with CC
Other Musculoskeletal System and Connective Tissue O.R. Procedures
517 1.3967 $8,977
without CC/MCC
907 Other O.R. Procedures for Injuries with MCC 3.9571 $25,434
908 Other O.R. Procedures for Injuries with CC 2.0404 $13,115
*MCC=Major Complications or Comorbidities
**CC=Complications or Comorbidities
2021 Reimbursement Guide DePuy Synthes 9Procedure Codes
Medicare uses The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and
Procedure Coding System (PCS) codes to identify diagnoses and procedures in the hospital inpatient setting. Hospitals
must report the principal diagnosis using the appropriate ICD-10-CM code, as well as any secondary diagnoses –
some of which may be considered CCs or MCCs for MS-DRG assignment. The principal diagnosis is defined in the
Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for
occasioning the admission of the patient to the hospital for care.” The circumstances of inpatient admission always
govern the selection of principal diagnosis.
For patient admissions involving procedures, hospitals must also report ICD-10-PCS procedure code(s) for the surgical
and other procedures as well as ICD-10-CM diagnosis codes.
Listed below are the ICD-10-PCS procedure codes associated with TRUMATCH® CMF Personalized Solutions for facial
reconstruction, orthognathic surgery, distraction and cranial reconstruction procedures.
ICD-10-PCS Description
0NB00ZZ Excision of Skull, Open Approach
0NBT0ZZ Excision of Right Mandible, Open Approach
0NBV0ZZ Excision of Left Mandible, Open Approach
0NQ00ZZ Repair Skull, Open Approach
0NQ10ZZ Repair Frontal Bone, Open Approach
0NQ30ZZ Repair Right Parietal Bone, Open Approach
0NQ40ZZ Repair Left Parietal Bone, Open Approach
0NQ50ZZ Repair Right Temporal Bone, Open Approach
0NQ60ZZ Repair Left Temporal Bone, Open Approach
0NQ70ZZ Repair Occipital Bone, Open Approach
0NRT07Z Replacement of Right Mandible with Autologous Tissue Substitute, Open Approach
0NRT0JZ Replacement of Right Mandible with Synthetic Substitute, Open Approach
0NRT0KZ Replacement of Right Mandible with Nonautologous Tissue Substitute, Open Approach
0NRV07Z Replacement of Left Mandible with Autologous Tissue Substitute, Open Approach
0NRV0JZ Replacement of Left Mandible with Synthetic Substitute, Open Approach
0NRV0KZ Replacement of Left Mandible with Nonautologous Tissue Substitute, Open Approach
0NSR04Z Reposition Maxilla with Internal Fixation Device, Open Approach
0NSR05Z Reposition Maxilla with External Fixation Device, Open Approach
0NST04Z Reposition Right Mandible with Internal Fixation Device, Open Approach
2021 Reimbursement Guide DePuy Synthes 100NST05Z Reposition Right Mandible with External Fixation Device, Open Approach
0NST0ZZ Reposition Right Mandible, Open Approach
0NSV04Z Reposition Left Mandible with Internal Fixation Device, Open Approach
0NSV05Z Reposition Left Mandible with External Fixation Device, Open Approach
0NSV0ZZ Reposition Left Mandible, Open Approach
0NU007Z Supplement Skull with Autologous Tissue Substitute, Open Approach
0NU00JZ Supplement Skull with Synthetic Substitute, Open Approach
0NU107Z Supplement Frontal Bone with Autologous Tissue Substitute, Open Approach
0NU10JZ Supplement Frontal Bone with Synthetic Substitute, Open Approach
0NU10KZ Supplement Frontal Bone with Nonautologous Tissue Substitute, Open Approach
0NU307Z Supplement Right Parietal Bone with Autologous Tissue Substitute, Open Approach
0NU30JZ Supplement Right Parietal Bone with Synthetic Substitute, Open Approach
0NU30KZ Supplement Right Parietal Bone with Nonautologous Tissue Substitute, Open Approach
0NU407Z Supplement Left Parietal Bone with Autologous Tissue Substitute, Open Approach
0NU40JZ Supplement Left Parietal Bone with Synthetic Substitute, Open Approach
0NU40KZ Supplement Left Parietal Bone with Nonautologous Tissue Substitute, Open Approach
0NU507Z Supplement Right Temporal Bone with Autologous Tissue Substitute, Open Approach
0NU50JZ Supplement Right Temporal Bone with Synthetic Substitute, Open Approach
0NU50KZ Supplement Right Temporal Bone with Nonautologous Tissue Substitute, Open Approach
0NU607Z Supplement Left Temporal Bone with Autologous Tissue Substitute, Open Approach
0NU707Z Supplement Occipital Bone with Autologous Tissue Substitute, Open Approach
0NUC07Z Supplement Sphenoid Bone with Autologous Tissue Substitute, Open Approach
0NUC0JZ Supplement Sphenoid Bone with Synthetic Substitute, Open Approach
0NUC0KZ Supplement Sphenoid Bone with Nonautologous Tissue Substitute, Open Approach
0NUF07Z Supplement Right Ethmoid Bone with Autologous Tissue Substitute, Open Approach
0NUG07Z Supplement Left Ethmoid Bone with Autologous Tissue Substitute, Open Approach
0NUH07Z Supplement Right Lacrimal Bone with Autologous Tissue Substitute, Open Approach
0NUJ07Z Supplement Left Lacrimal Bone with Autologous Tissue Substitute, Open Approach
0NUK07Z Supplement Right Palatine Bone with Autologous Tissue Substitute, Open Approach
0NUL07Z Supplement Left Palatine Bone with Autologous Tissue Substitute, Open Approach
0NUM07Z Supplement Right Zygomatic Bone with Autologous Tissue Substitute, Open Approach
0NUN07Z Supplement Left Zygomatic Bone with Autologous Tissue Substitute, Open Approach
0NUP07Z Supplement Right Orbit with Autologous Tissue Substitute, Open Approach
2021 Reimbursement Guide DePuy Synthes 110NUP0JZ Supplement Right Orbit with Synthetic Substitute, Open Approach
0NUP0KZ Supplement Right Orbit with Nonautologous Tissue Substitute, Open Approach
0NUQ07Z Supplement Left Orbit with Autologous Tissue Substitute, Open Approach
0NUQ0JZ Supplement Left Orbit with Synthetic Substitute, Open Approach
0NUQ0KZ Supplement Left Orbit with Nonautologous Tissue Substitute, Open Approach
0NUT07Z Supplement Right Mandible with Autologous Tissue Substitute, Open Approach
0NUT0JZ Supplement Right Mandible with Synthetic Substitute, Open Approach
0NUT0KZ Supplement Right Mandible with Nonautologous Tissue Substitute, Open Approach
0NUV07Z Supplement Left Mandible with Autologous Tissue Substitute, Open Approach
0NUV0JZ Supplement Left Mandible with Synthetic Substitute, Open Approach
0NUV0KZ Supplement Left Mandible with Nonautologous Tissue Substitute, Open Approach
0W0407Z Alteration of Upper Jaw with Autologous Tissue Substitute, Open Approach
0W040JZ Alteration of Upper Jaw with Synthetic Substitute, Open Approach
0W040KZ Alteration of Upper Jaw with Nonautologous Tissue Substitute, Open Approach
0W0507Z Alteration of Lower Jaw with Autologous Tissue Substitute, Open Approach
0W050JZ Alteration of Lower Jaw with Synthetic Substitute, Open Approach
0W050KZ Alteration of Lower Jaw with Nonautologous Tissue Substitute, Open Approach
2021 Reimbursement Guide DePuy Synthes 12Diagnosis Codes
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes
entered on hospital and physician claims are important in conveying information about the patient’s condition to
payers. All healthcare providers must report the principal diagnosis using the appropriate ICD- 10-CM code, as well
as any secondary diagnoses. Payers use this information to evaluate the medical necessity for the episode of care
and the appropriateness of the treatment the patient received.
Diagnosis codes should be reported to the highest level of specificity available – a code is invalid if it has not been
coded to the full number of digits required for that code. The table below includes examples only of ICD-10-CM
diagnosis codes associated with conditions related to facial reconstruction, orthognathic surgery, distraction and
cranial reconstruction procedures.
ICD-10-CM Description (See current ICD-10-CM Diagnosis book for complete descriptions)
C03.0 Malignant neoplasm of upper gum
C41.0 Malignant neoplasm of bones of skull and face
C41.1 Malignant neoplasm of mandible
C79.51 Secondary malignant neoplasm of bone
D16.4 Benign neoplasm of bones of skull and face
D16.5 Benign neoplasm of lower jaw bone
D48.0 Neoplasm of uncertain behavior of bone and articular cartilage
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
H05.30 Unspecified deformity of orbit
H05.311 Atrophy of right orbit
H05.312 Atrophy of left orbit
H05.313 Atrophy of bilateral orbit
H05.319 Atrophy of unspecified orbit
H05.321 Deformity of right orbit due to bone disease
H05.322 Deformity of left orbit due to bone disease
H05.323 Deformity of bilateral orbits due to bone disease
H05.329 Deformity of unspecified orbit due to bone disease
H05.331 Deformity of right orbit due to trauma or surgery
H05.332 Deformity of left orbit due to trauma or surgery
H05.333 Deformity of bilateral orbits due to trauma or surgery
H05.339 Deformity of unspecified orbit due to trauma or surgery
H05.341 Enlargement of right orbit
H05.342 Enlargement of left orbit
H05.343 Enlargement of bilateral orbits
H05.349 Enlargement of unspecified orbit
H05.351 Exostosis of right orbit
H05.352 Exostosis of left orbit
2021 Reimbursement Guide DePuy Synthes 13H05.353 Exostosis of bilateral orbits
H05.359 Exostosis of unspecified orbit
H05.89 Other disorders of orbit
K04.8 Radicular cyst
K09.0 Developmental odontogenic cysts
M26.00 Unspecified anomaly of jaw size
M26.01 Maxillary hyperplasia
M26.02 Maxillary hypoplasia
M26.03 Mandibular hyperplasia
M26.04 Mandibular hypoplasia
M26.09 Other specified anomalies of jaw size
M26.10 Unspecified anomaly of jaw-cranial base relationship
M26.11 Maxillary asymmetry
M26.12 Other jaw asymmetry
M26.19 Other specified anomalies of jaw-cranial base relationship
M26.211 Malocclusion, Angle's class I
M26.212 Malocclusion, Angle's class II
M26.213 Malocclusion, Angle's class III
M26.219 Malocclusion, Angle's class, unspecified
M26.220 Open anterior occlusal relationship
M26.221 Open posterior occlusal relationship
M26.23 Excessive horizontal overlap
M26.24 Reverse articulation
M26.25 Anomalies of interarch distance
M26.29 Other anomalies of dental arch relationship
M26.30 Unspecified anomaly of tooth position of fully erupted tooth or teeth
M26.31 Crowding of fully erupted teeth
M26.32 Excessive spacing of fully erupted teeth
M26.33 Horizontal displacement of fully erupted tooth or teeth
M26.34 Vertical displacement of fully erupted tooth or teeth
M26.35 Rotation of fully erupted tooth or teeth
M26.36 Insufficient interocclusal distance of fully erupted teeth (ridge)
M26.37 Excessive interocclusal distance of fully erupted teeth
M26.39 Other anomalies of tooth position of fully erupted tooth or teeth
M26.4 Malocclusion, unspecified
M26.50 Dentofacial functional abnormalities, unspecified
M26.51 Abnormal jaw closure
M26.52 Limited mandibular range of motion
M26.53 Deviation in opening and closing of the mandible
M26.59 Other dentofacial functional abnormalities
M26.70 Unspecified alveolar anomaly
2021 Reimbursement Guide DePuy Synthes 14M26.71 Alveolar maxillary hyperplasia
M26.72 Alveolar mandibular hyperplasia
M26.73 Alveolar maxillary hypoplasia
M26.74 Alveolar mandibular hypoplasia
M26.79 Other specified alveolar anomalies
M26.89 Other dentofacial anomalies
M26.9 Dentofacial anomaly, unspecified
M27.0 Developmental disorders of jaws
M27.1 Giant cell granuloma, central
M27.40 Unspecified cyst of jaw
M27.49 Other cysts of jaw
M27.8 Other specified diseases of jaws
M86.9 Osteomyelitis, unspecified
M87.08 Idiopathic aseptic necrosis of bone, other site
M87.180 Osteonecrosis due to drugs, jaw
M89.38 Hypertrophy of bone, other site
M95.0 Acquired deformity of nose
M95.2 Other acquired deformity of head
M99.80 Other biomechanical lesions of head region
Q00.0 Anencephaly
Q00.1 Craniorachischisis
Q00.2 Iniencephaly
Q02 Microcephaly
Q04.5 Megalencephaly
Q04.8 Other specified congenital malformations of brain
Q04.9 Congenital malformation of brain, unspecified
Q10.7 Congenital malformation of orbit
Q18.8 Other specified congenital malformations of face and neck
Q18.9 Congenital malformation of face and neck, unspecified
Q30.1 Agenesis and underdevelopment of nose
Q30.2 Fissured, notched and cleft nose
Q30.3 Congenital perforated nasal septum
Q30.8 Other congenital malformations of nose
Q30.9 Congenital malformation of nose, unspecified
Q67.0 Congenital facial asymmetry
Q67.1 Congenital compression facies
Q67.2 Dolichocephaly
Q67.3 Plagiocephaly
Q67.4 Other congenital deformities of skull, face and jaw
Q75.0 Craniosynostosis
Q75.1 Craniofacial dysostosis
2021 Reimbursement Guide DePuy Synthes 15Q75.2 Hypertelorism
Q75.3 Macrocephaly
Q75.4 Mandibulofacial dysostosis
Q75.5 Oculomandibular dysostosis
Q75.8 Other specified congenital malformations of skull and face bones
Q75.9 Congenital malformation of skull and face bones, unspecified
Q87.0 Congenital malformation syndromes predominantly affecting facial appearance
S02.0XXA Fracture of vault of skull, initial encounter for closed fracture
S02.0XXB Fracture of vault of skull, initial encounter for open fracture
S02.121A Fracture of orbital roof, right side, initial encounter for closed fracture
S02.121B Fracture of orbital roof, right side, initial encounter for open fracture
S02.122A Fracture of orbital roof, left side, initial encounter for closed fracture
S02.122B Fracture of orbital roof, left side, initial encounter for open fracture
S02.129A Fracture of orbital roof, unspecified side, initial encounter for closed fracture
S02.129B Fracture of orbital roof, unspecified side, initial encounter for open fracture
S02.2XXA Fracture of nasal bones, initial encounter for closed fracture
S02.2XXB Fracture of nasal bones, initial encounter for open fracture
S02.30XA Fracture of orbital floor, unspecified side, initial encounter for closed fracture
S02.30XB Fracture of orbital floor, unspecified side, initial encounter for open fracture
S02.31XA Fracture of orbital floor, right side, initial encounter for closed fracture
S02.31XB Fracture of orbital floor, right side, initial encounter for open fracture
S02.32XA Fracture of orbital floor, left side, initial encounter for closed fracture
S02.32XB Fracture of orbital floor, left side, initial encounter for open fracture
S02.400A Malar fracture, unspecified side, initial encounter for closed fracture
S02.400B Malar fracture, unspecified side, initial encounter for open fracture
S02.401A Maxillary fracture, unspecified side, initial encounter for closed fracture
S02.401B Maxillary fracture, unspecified side, initial encounter for open fracture
S02.402A Zygomatic fracture, unspecified side, initial encounter for closed fracture
S02.402B Zygomatic fracture, unspecified side, initial encounter for open fracture
S02.40AA Malar fracture, right side, initial encounter for closed fracture
S02.40AB Malar fracture, right side, initial encounter for open fracture
S02.40BA Malar fracture, left side, initial encounter for closed fracture
S02.40BB Malar fracture, left side, initial encounter for open fracture
S02.40CA Maxillary fracture, right side, initial encounter for closed fracture
S02.40CB Maxillary fracture, right side, initial encounter for open fracture
S02.40DA Maxillary fracture, left side, initial encounter for closed fracture
S02.40DB Maxillary fracture, left side, initial encounter for open fracture
S02.40EA Zygomatic fracture, right side, initial encounter for closed fracture
S02.40EB Zygomatic fracture, right side, initial encounter for open fracture
S02.40FA Zygomatic fracture, left side, initial encounter for closed fracture
S02.40FB Zygomatic fracture, left side, initial encounter for open fracture
2021 Reimbursement Guide DePuy Synthes 16S02.411A LeFort I fracture, initial encounter for closed fracture
S02.411B LeFort I fracture, initial encounter for open fracture
S02.412A LeFort II fracture, initial encounter for closed fracture
S02.412B LeFort II fracture, initial encounter for open fracture
S02.413A LeFort III fracture, initial encounter for closed fracture
S02.413B LeFort III fracture, initial encounter for open fracture
S02.42XA Fracture of alveolus of maxilla, initial encounter for closed fracture
S02.42XB Fracture of alveolus of maxilla, initial encounter for open fracture
S02.631A Fracture of coronoid process of right mandible, initial encounter for closed fracture
S02.631B Fracture of coronoid process of right mandible, initial encounter for open fracture
S02.632A Fracture of coronoid process of left mandible, initial encounter for closed fracture
S02.632B Fracture of coronoid process of left mandible, initial encounter for open fracture
S02.640A Fracture of ramus of mandible, unspecified side, initial encounter for closed fracture
S02.640B Fracture of ramus of mandible, unspecified side, initial encounter for open fracture
S02.641A Fracture of ramus of right mandible, initial encounter for closed fracture
S02.641B Fracture of ramus of right mandible, initial encounter for open fracture
S02.642A Fracture of ramus of left mandible, initial encounter for closed fracture
S02.642B Fracture of ramus of left mandible, initial encounter for open fracture
S02.650A Fracture of angle of mandible, unspecified side, initial encounter for closed fracture
S02.650B Fracture of angle of mandible, unspecified side, initial encounter for open fracture
S02.651A Fracture of angle of right mandible, initial encounter for closed fracture
S02.651B Fracture of angle of right mandible, initial encounter for open fracture
S02.652A Fracture of angle of left mandible, initial encounter for closed fracture
S02.652B Fracture of angle of left mandible, initial encounter for open fracture
S02.66XA Fracture of symphysis of mandible, initial encounter for closed fracture
S02.66XB Fracture of symphysis of mandible, initial encounter for open fracture
S02.670A Fracture of alveolus of mandible, unspecified side, initial encounter for closed fracture
S02.670B Fracture of alveolus of mandible, unspecified side, initial encounter for open fracture
S02.671A Fracture of alveolus of right mandible, initial encounter for closed fracture
S02.671B Fracture of alveolus of right mandible, initial encounter for open fracture
S02.672A Fracture of alveolus of left mandible, initial encounter for closed fracture
S02.672B Fracture of alveolus of left mandible, initial encounter for open fracture
S02.69XA Fracture of mandible of other specified site, initial encounter for closed fracture
S02.69XB Fracture of mandible of other specified site, initial encounter for open fracture
Fracture of other specified skull and facial bones, unspecified side, initial encounter for
S02.80XA
closed fracture
Fracture of other specified skull and facial bones, unspecified side, initial encounter for
S02.80XB
open fracture
Fracture of other specified skull and facial bones, right side, initial encounter for closed
S02.81XA
fracture
Fracture of other specified skull and facial bones, right side, initial encounter for open
S02.81XB
fracture
2021 Reimbursement Guide DePuy Synthes 17Fracture of other specified skull and facial bones, left side, initial encounter for closed
S02.82XA
fracture
Fracture of other specified skull and facial bones, left side, initial encounter for open
S02.82XB
fracture
S02.85XA Fracture of orbit, unspecified, initial encounter for closed fracture
S02.85XB Fracture of orbit, unspecified, initial encounter for open fracture
S02.92XA Unspecified fracture of facial bones, initial encounter for closed fracture
S02.92XB Unspecified fracture of facial bones, initial encounter for open fracture
S07.0XXA Crushing injury of face, initial encounter
S07.1XXA Crushing injury of skull, initial encounter
Z41.1 Encounter for cosmetic surgery
Encounter for other plastic and reconstructive surgery following medical procedure or
Z42.8
healed injury
2021 Reimbursement Guide DePuy Synthes 18HCPCS Codes and Revenue Codes
Medicare uses HCPCS (C-codes) to track device cost information for future APC rate-setting purposes. No additional
payment will be provided to the facility. All appropriate C-codes should be added to the hospital’s chargemaster to
report device costs used in the outpatient setting. CMS will return a hospital claim if the appropriate tracking code is
not identified on the claim when a device-dependent procedure is performed. The tables below may be referenced
when reporting various DePuy Synthes fixation and radial head arthroplasty products.
HCPCS Code Description
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable). Implantable pins and/or
screws that are used to oppose soft tissue-to-bone, tendon-to-bone, or bone-to-bone. Screws oppose
tissues via drilling as follows: soft tissue-to-bone, tendon-to-bone, or bone-to-bone fixation. Pins are
C1713 inserted or drilled into bone, principally with the intent to facilitate stabilization or oppose bone-to-bone.
This may include orthopedic plates with accompanying washers and nuts. This category also applies to
synthetic bone substitutes that may be used to fill bony void or gaps (i.e., bone substitute
implanted into a bony defect created from trauma or surgery).
L8699 Prosthetic implant, not otherwise specified
Revenue codes allow hospitals to categorize services provided by revenue center for cost reporting. For Medicare,
revenue codes must be included for each service on a CMS 1450 (UB-04) claim form. Sample revenue codes that
hospital facilities may use to track costs for services associated with facial reconstruction, orthognathic surgery,
distraction and cranial reconstruction procedures are listed in the following table.
Revenue Code Description
0270 Medical/Surgical Supplies
0271 Medical/Surgical Supplies: Non-sterile
0272 Medical/Surgical Supplies: Sterile
0278 Medical/Surgical Supplies: Other Implants
2021 Reimbursement Guide DePuy Synthes 19Modifiers
The modifiers outlined below may be used to report special circumstance during facial reconstruction, orthognathic
surgery, distraction and cranial reconstruction procedures. These include some of the most common modifiers used in
conjunction with these surgeries and do not represent a full listing. Please refer to the most up to date version of the
AMA CPT® Code book for a complete listing.
Modifiers Description
Increased Procedural Services: When the work required to provide a service is substantially greater than typically
required, it may be identified by adding modifier 22 to the usual procedure code.
22 Documentation must support the substantial additional work and the reason for the additional work (ie, increased
intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).
Note: This modifier should not be appended to an E/M service.
Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same
50
session should be identified by adding modifier 50 to the appropriate 5-digit code.
Multiple Procedures: When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation
services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the
51 primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by
appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended
to designated “add-on” codes (see Appendix F).
Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the
discretion of the physician or other qualified health care professional. Under these circumstances the service
provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service
is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic
52
service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced
or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or
after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient
use).
Discontinued Procedure: Under certain circumstances, the physician or other qualified health care professional
may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten
the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but
discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for
the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior
53
to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/
ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or
cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or
after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient
use).
Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Profes-
sional During the Postoperative Period: It may be necessary to indicate that the performance of a procedure
or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the
58
original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by ad-
ding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to
the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
2021 Reimbursement Guide DePuy Synthes 20Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or
service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used
to identify procedures/services, other than E/M services, that are not normally reported together, but are
appropriate under the circumstances. Documentation must support a different session, different procedure or
surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of
59
injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
However, when another already established modifier is appropriate it should be used rather than modifier 59.
Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances,
should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate
and distinct E/M service with a non- E/M service performed on the same date, see modifier 25.
Repeat Procedure or Service by the Same Physician or Other Healthcare Professional: It may be necessary
to indicate that a procedure or service was repeated by the same physician or other qualified health care
76
professional subsequent to the original procedure or service. This circumstance may be reported by adding
modifier 76 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service.
Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified
Healthcare Professional Following Initial Procedure for a Related Procedure During the Postoperative
Period: It may be necessary to indicate that another procedure was performed during the postoperative period
78
of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the
first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the
related procedure. (For repeat procedures, see modifier 76.)
Unrelated Procedure or Service by the Same Physician During the Postoperative Period: The individual
may need to indicate that the performance of a procedure or service during the postoperative period was
79
unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat
procedures on the same day, see modifier 76.)
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
2021 Reimbursement Guide DePuy Synthes 21Notes
Not all codes provided are applicable for the recommended uses of DePuy Synthes products. The most appropriate
code for the patient’s clinical presentation must be selected. CPT® copyright 2020 American Medical Association. All
rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS/DFARS
Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related
components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The
AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for
data contained or not contained herein.
Sources
Calendar Year 2021 Medicare Outpatient Prospective Payment System, Final Rule [CMS-1736-FC], Federal Register,
December 2, 2020 and its associated addenda. Medicare payment allowable rates shown above do not reflect the
automatic payment cuts required under the sequestration process of the 2011 Budget Control Act. Calendar Year
2021 Medicare Physician Fee Schedule, Final Rule [CMS-1734-F]. Federal Register, December 02, 2020. No
geographic adjustments have been made to the reported payment rates. Calendar Year 2021 Medicare Inpatient
Final Rule, Final Rule [CMS-1735-F] and [CMS-1735-CN]. Federal Register, September 02, 2020 and December 01,
2020. No geographic adjustments have been made to the reported payment rates. Final National Average DRG
Payment.
Status Indicator (SI) Definitions
J1 - Hospital Part B services paid through a Comprehensive APC. Q2 - If criteria are not met, payment is
packaged into payment for other services, including outliers. Therefore, there is no separate APC payment.
Payment Indicator (PI) Definitions
A2 - Surgical procedure on ASC list in CY 2007, payment based on OPPS relative payment weight; J8 - Device-
intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate.
FOR ADDITIONAL QUESTIONS OR INFORMATION CONTACT
DePuy Synthes Reimbursement Support Services
800-410-8177
DePuySynthes@avaniareimbursement.com
Please refer to the instructions for use for a complete list of indications, contraindications, warnings and precautions.
© DePuy Synthes 2021. All rights reserved. 163478-201222 DSUS The third party trademarks used herein are the trademarks of their respective owners.You can also read
