LeFort I fracture
ICD-10 S02.411 is a billable code used to indicate a diagnosis of lefort i fracture.
A LeFort I fracture is a type of maxillary fracture that involves a horizontal fracture of the maxilla, separating the upper jaw from the base of the skull. This injury typically occurs due to high-impact trauma, such as motor vehicle accidents, falls, or physical assaults. Clinically, patients may present with facial swelling, malocclusion, and nasal bleeding. The fracture can disrupt the dental arch and may lead to complications such as airway obstruction or facial deformity if not properly managed. Diagnosis is primarily through clinical examination and imaging studies, including CT scans, which provide detailed visualization of the fracture pattern. Management often involves surgical intervention to realign the maxilla and stabilize the fracture using plates and screws. Post-operative care is crucial to monitor for complications such as infection, non-union, or malocclusion. Accurate coding of this injury is essential for proper reimbursement and tracking of trauma-related injuries.
Documentation must include details of the mechanism of injury, initial assessment findings, and any imaging results.
Patients presenting with facial trauma after a car accident or physical altercation.
Ensure that the documentation reflects the urgency of the injury and any immediate interventions performed.
Operative reports must detail the surgical approach, fixation methods, and any intraoperative findings.
Surgical repair of a LeFort I fracture following trauma.
Accurate coding of surgical procedures is critical, including any additional procedures performed during the same surgical session.
Used during surgical repair of a LeFort I fracture.
Operative report must detail the surgical approach and fixation method.
Ensure that the procedure is linked to the correct diagnosis code.
LeFort I fractures are primarily caused by high-impact trauma, such as motor vehicle accidents, falls, or physical assaults.
Diagnosis is typically made through clinical examination and confirmed with imaging studies, particularly CT scans.
Complications can include airway obstruction, malocclusion, and infection at the surgical site.
