LeFort I (Maxilla) - CDT Code Guide
Overview
CDT code D7946 refers to the LeFort I procedure, a surgical intervention involving the sectioning of the upper jaw, or maxilla. This complex procedure includes the exposure of the surgical site, precise bone cuts, downfracture, repositioning of the maxilla, and fixation. It concludes with routine wound closure and encompasses normal post-operative follow-up care. Typically, this procedure is utilized in cases of severe maxillary deformities, such as those resulting from trauma, congenital defects, or severe malocclusion. It is a critical component in the correction of facial asymmetries and can significantly improve both function and aesthetics for patients.
When to Use This Code
- Correction of maxillary hypoplasia or retrusion
- Treatment of severe malocclusion requiring surgical intervention
- Reconstruction following trauma to the maxillary region
- Addressing congenital facial deformities affecting the maxilla
- Preparation for orthognathic surgery to improve occlusion and facial balance
Documentation Requirements
- Detailed surgical report including the steps of the procedure
- Pre-operative and post-operative imaging studies
- Patient consent forms specific to the surgical procedure
- Comprehensive patient history and diagnosis supporting the need for surgery
- Post-operative care instructions and follow-up visit documentation
Billing Considerations
When billing for D7946, it is important to note any frequency limitations imposed by insurance providers. Common modifiers may include those indicating bilateral procedures or additional complexity. Ensure that all pre-authorization requirements are met, as this procedure is often subject to scrutiny by insurance companies due to its complexity and cost.
Related CDT Codes
Frequently Asked Questions
The LeFort I procedure is primarily used to correct maxillary deformities, improve occlusion, and enhance facial symmetry.
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