Surgical · Other

21150

Reconstruction of the midface via a modified Le Fort II osteotomy pattern that advances the nasal-orbital complex anteriorly without mobilizing the zygoma.

Verified May 8, 2026 · 4 sources ↓

Medicare
$1,415.20
Total RVUs
42.37
Global, days
90
Region
Other
Drawn from CMSCgsmedicareAAOS

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 4 cited references ↓

  • Specify osteotomy pattern by name (Le Fort II) and confirm zygomatic arches were NOT mobilized — distinguishes 21150 from 21154/21155/21160
  • Document the underlying diagnosis driving midface retrusion (e.g., Crouzon syndrome, Apert syndrome, post-traumatic deformity) with ICD-10 linkage
  • Describe functional impairment: obstructive sleep apnea, exorbitism, malocclusion, or airway obstruction — required for medical necessity under most payers
  • Record bone graft harvest site and graft type separately if an interpositional or onlay graft was placed (may support add-on coding)
  • Document fixation hardware used (plates, screws) and their placement locations in the operative note
  • Note intraoperative imaging or navigation use if applicable — fluoroscopy bundled per NCCI general policy unless a separate identifiable service
  • Anesthesia type and any monitored parameters supporting general anesthesia medical necessity

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

What this code covers

Source · Editorial summary grounded in 4 cited references ↓

CPT 21150 describes a Le Fort II-type midface reconstruction — an osteotomy pattern that cuts through the nasal bones, medial orbital walls, and across the maxilla to mobilize the central midface (nose, orbital floor, and upper jaw) as a single unit. Unlike Le Fort III, the zygomatic arches are not included. The procedure corrects midface retrusion affecting the nasomaxillary complex, most often in patients with craniofacial dysostoses (Crouzon, Apert) or post-traumatic midface collapse where the zygomas are adequately positioned.

The 90-day global period covers all routine postoperative management through day 90, including wound checks, suture removal, and standard imaging reviews. Any new problem unrelated to the reconstruction — or a staged secondary procedure — requires modifier 79. An unplanned return to the OR for a complication (e.g., hardware failure, airway compromise) is billed with modifier 78.

Site of service matters significantly here. The HOPD and ASC payment differentials are substantial; see the site-of-service comparison rendered on this page. Most payers require prior authorization given the high RVU value (42.37 total) and the elective-reconstructive nature of the procedure. Commercial carriers frequently scrutinize medical necessity documentation distinguishing functional impairment from purely aesthetic correction.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU25.31
Practice expense RVU13.37
Malpractice RVU3.69
Total RVU42.37
Medicare national rate$1,415.20
Global period90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

SettingMedicare rate (national)
Office (PFS non-facility)
Procedure performed in physician's office
$1,415.20
HOPD (APC 5165)
Hospital outpatient department
$6,048.05
ASC (PI J8)
Ambulatory surgical center (freestanding)
$3,833.49

Common denial reasons

The recurring reasons claims for CPT 21150 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

  • Wrong code level selected — payers downcode to 21141 or 21145 when operative note does not explicitly confirm a Le Fort II cut pattern
  • Medical necessity not established — cosmetic vs. functional distinction is absent or ambiguous in the clinical record
  • Missing or inadequate prior authorization — high-RVU craniofacial codes are routinely flagged for preauthorization by commercial payers
  • Global period conflict — E/M or follow-up services billed within the 90-day window without modifier 24 (unrelated) attached
  • Bundling edit triggered when bone graft harvest (e.g., 20900–20902) is billed without appropriate modifier demonstrating a distinct surgical site or service

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 4 cited references ↓

01What distinguishes CPT 21150 from 21154 and 21155?
21150 is a Le Fort II advancement — central midface only, zygomatic arches stay fixed. 21154 adds a Le Fort III component (total midface including zygomas) without bone grafts; 21155 adds bone grafts to that Le Fort III. If the operative note confirms zygoma mobilization, 21150 is the wrong code.
02Can you bill a bone graft harvest separately with 21150?
Yes, if the graft is harvested from a separate anatomical site (e.g., iliac crest, calvarium), report the appropriate harvest code (20900–20902 range) with modifier 59 or XS to document the distinct site. Grafts that are a direct byproduct of the osteotomy cuts themselves are not separately reportable.
03Is modifier 22 defensible for this procedure?
Yes, when documented. Revision of a prior Le Fort II, severe scar tissue from prior trauma or infection, or unusually complex anatomy can support modifier 22. The operative note must quantify the additional work — time, difficulty, or added steps — and the claim should include a cover letter. Expect a 15–30% upward review, not automatic payment.
04How does the 90-day global period affect E/M billing postoperatively?
Routine follow-up E/M visits in the 90-day window are bundled — do not bill them separately. If the patient presents for a new, unrelated problem within the global period, attach modifier 24 to the E/M. If you're performing a related staged procedure, use modifier 58.
05Which payers require prior authorization for 21150?
Most commercial payers and Medicare Advantage plans require prior authorization for craniofacial reconstruction codes in the 21100s given their high RVU weight. Traditional Medicare (Parts A and B) does not require prior auth, but MACs may conduct post-payment review. Always verify with the specific plan before scheduling.
06Can 21150 and orthognathic procedures (e.g., 21195–21199) be billed on the same date?
Only when distinct, separately identifiable procedures are performed at anatomically different sites and documented as such. NCCI bundling logic for the musculoskeletal chapter treats inclusive components of the same surgical field as non-separately reportable. Use modifier 59 or XS with solid operative-note support if billing both, and expect payer scrutiny.

Mira AI Scribe

Mira's AI scribe captures the osteotomy pattern name, cut boundaries (nasal bones, medial orbital walls, pterygoid plates), structures mobilized, fixation method, graft harvest site if applicable, and the functional indication driving the procedure. That detail prevents downcoding to a less complex Le Fort level and supplies the medical necessity language payers require to clear prior-authorization and clinical review denials.

See how Mira captures CPT 21150 documentation

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