LeFort II fracture, initial encounter for closed fracture

This code signifies a LeFort II fracture, which is a midfacial fracture characterized by separation of the maxilla from the skull base, often involving the nasal bones, medial orbital walls, and pterygoid plates. It is a closed fracture, meaning there is no open wound communicating with the fracture site.

Apply this code when documentation clearly states a LeFort II fracture and specifies it as a closed injury. This code is appropriate for the initial treatment of the fracture, such as during emergency department visits, initial surgical repair, or the first encounter for definitive management. Supporting documentation includes imaging reports (CT scans, X-rays) confirming the fracture pattern and physician notes detailing the closed nature of the injury.

• Ensure the documentation explicitly distinguishes between LeFort I, II, and III fractures, as they represent different anatomical involvements.
• Verify the encounter type; the "A" suffix indicates an initial encounter for active treatment. Subsequent encounters for routine healing or follow-up would use different seventh characters.
• Do not use this code if the fracture is open; a different code with an "B" or "C" suffix would be appropriate for an open fracture.