Overview of CPT Code 21453: Open treatment of clavicle fracture

CPT Code 21453 refers to the surgical procedure for the open treatment of a clavicle fracture, which involves realigning and stabilizing the broken bone through an incision.

When CPT Code 21453 is Used?

This procedure is indicated in specific clinical scenarios.

Displaced clavicle fractures that cannot heal properly without surgical intervention.
Fractures associated with significant displacement or shortening of the clavicle.
Fractures that are open or involve the skin, requiring surgical treatment to prevent infection.

Symptoms Indicating This Procedure

Patients may present with various symptoms that suggest the need for surgical intervention.

Severe pain at the site of the fracture.
Swelling and bruising over the shoulder area.
Inability to move the arm or shoulder without pain.
Visible deformity or abnormal positioning of the shoulder.

Causes and Risk Factors

Understanding the causes and risk factors can help in prevention.

Traumatic injuries from falls, sports, or accidents.
High-impact activities that increase the risk of fractures.
Osteoporosis or other conditions that weaken bones.

Diagnostic Tests Before Procedure

Several diagnostic tests may be performed to confirm the need for surgery.

X-rays to visualize the fracture and assess its alignment.
CT scans for detailed imaging if the fracture is complex.
Physical examination to evaluate the range of motion and pain.

Procedure Description

The open treatment of a clavicle fracture involves several key steps.

Administer anesthesia to ensure patient comfort.
Make an incision over the fracture site to access the clavicle.
Realign the fractured bone fragments into their proper position.
Stabilize the fracture using plates, screws, or other fixation devices.
Close the incision with sutures and apply a dressing.

Preparation for the Procedure

Proper preparation is essential for a successful surgery.

Avoid eating or drinking for at least 8 hours before surgery.
Discuss any medications with your surgeon, especially blood thinners.
Arrange for transportation to and from the surgical facility.

Recovery and Aftercare

Post-operative care is crucial for healing.

Expected recovery period is typically 6 to 12 weeks.
Keep the surgical site clean and dry; follow wound care instructions.
Pain management may include prescribed medications or over-the-counter pain relievers.
Physical therapy may be recommended to restore strength and mobility.

Possible Complications

While complications are rare, they can occur.

Infection at the surgical site.
Nonunion or malunion of the fracture.
Nerve or blood vessel damage.
Persistent pain or stiffness in the shoulder.

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Post-Procedure Follow-Up

Regular follow-up is important to monitor recovery.

Initial follow-up visit within 1 to 2 weeks post-surgery.
Subsequent visits every 4 to 6 weeks to assess healing.
X-rays may be taken during follow-ups to ensure proper bone healing.

Alternative Treatments

Non-surgical options may be considered in certain cases.

Immobilization with a sling for non-displaced fractures.
Physical therapy to strengthen surrounding muscles.
Pain management with medications and rest.

Home Care Tips

Patients can take steps at home to aid recovery.

Follow all post-operative care instructions provided by your surgeon.
Keep the arm elevated to reduce swelling.
Engage in gentle movements as advised to prevent stiffness.

Patient Education & Prevention

Education is key to preventing future injuries.

Wear protective gear during sports and high-risk activities.
Maintain bone health through a balanced diet rich in calcium and vitamin D.
Engage in strength training to improve bone density.

Billing and Coding Information

CPT Code: 21453

Category: Surgical Procedures

Common Modifiers:

50 - Bilateral procedure
RT - Right side
LT - Left side

Average Cost and Insurance Coverage

Costs can vary based on several factors.

Average cost ranges from $5,000 to $15,000 depending on facility and complexity.
Most insurance plans cover the procedure if deemed medically necessary.