Analyzing Variation in Fronto-Orbital Advancement Coding: Insights From 2569 Cases

This study characterizes national billing practices for temporalis muscle flaps in fronto-orbital advancement (FOA). A retrospective cohort analysis was conducted using deidentified data from the Pediatric National Surgical Quality Improvement Program (PNSQIP), 2016 to 2021. Pediatric patients undergoing FOA were identified by CPT code 21175, and cases were categorized by the presence or absence of additional CPT codes 15732/15733 for temporalis muscle flaps. Perioperative variables included operative time, anesthesia time, length of stay, and primary surgical specialty. Among 2569 FOA cases, 601 (23.4%) included additional temporalis muscle flap codes. Operative time (254 ± 7.8 versus 240.6 ± 4.3 min; P = 0.003) and anesthesia time (369.2 ± 8.9 versus 353.3 ± 4.8 min; P = 0.002) were longer in cases with flap codes, while length of stay did not differ (P = 0.077). Plastic surgeons were listed as the primary specialty in most FOAs (57.2%) and were more likely to include flap codes compared with otolaryngologists (24.6% versus 9.6%; P = 0.013). Nearly one quarter of FOA cases included temporalis muscle flap codes, despite temporalis dissection being inherent to the procedure. This variation reflects differences in billing interpretation rather than operative technique and highlights the need for standardized coding guidelines to ensure transparency and equitable reimbursement in craniofacial surgery.