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Clinical Indicators: Le Fort Fracture

Clinical Indicators: Le Fort Fracture
Approach ProcedureCPTRBRVS Global Days
LeFort I, Treatment of palatal or maxillary fracture, with interdental wire fixation of
denture or splint, closed
2142190
LeFort I, Treatment of palatal or maxillary fracture, with interdental wire fixation of
denture or splint, open
2142290
LeFort I, Treatment of palatal or maxillary fracture, with interdental wire fixation of
denture or splint, complicated, multiple approaches
2142390
LeFort II, Closed treatment of nasomaxillary complex fracture with interdental wiring fixation or fixation of denture or splint2134590
LeFort II, Open with wiring and/or local fixation2134690
LeFort II, Open with wiring and/or local fixation, requiring multiple approaches2134790
LeFort II, Open with wiring and/or local fixation, multiple approaches with bone grafting2134890
LeFort III, Closed treatment of craniofacial separation using interdental wire fixation of
denture or splint
2143190
LeFort III, Open treatment of craniofacial separation, with wiring and/or internal fixation2143290
LeFort III, Open treatment of craniofacial separation, with wiring and/or internal fixation, complicated, multiple approaches2143390
LeFort III, Open treatment of craniofacial separation, with wiring and/or internal fixation, complicated, using internal and/or external fixation 2143590
LeFort III, Open treatment of craniofacial separation, with wiring and/or internal fixation, complicated, multiple approaches, internal fixation with bone grafting2143690
Additional Approach ProcedureCPTRBRVS Global Days
Tracheostomy, planned (separate procedure) 316000
Bone graft, any donor area; minor or small (e.g., dowel or button) 2090090
Bone graft, any donor area; major or large2090290
Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)2090890
Cartilage graft; costochondral2091090
Graft; rib cartilage, autogeneous to face, chin, nose or ear (includes
obtaining graft)
2123090
  1. 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
  2. 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
  3. 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

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

Outcome Review

  1. 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
  2. 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


© 2014 American Academy of Otolaryngology-Head and Neck Surgery. 1650 Diagonal Road, Alexandria, VA 22314.

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