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Forehead reduction surgery, specifically described by CPT® Code 21138, is a surgical procedure aimed at reducing and reshaping a prominent or asymmetrical frontal bone in the forehead region. This procedure is particularly relevant for individuals who may have an overly prominent forehead or asymmetrical features that can affect their appearance and self-esteem. The surgery begins with an incision made at the junction of the forehead and the hairline, allowing access to the underlying structures. The skin and soft tissues of the forehead are carefully undermined to the level of the brows, exposing the frontal bone. Unlike the procedure described in CPT® Code 21137, which involves contouring alone, CPT® Code 21138 incorporates both contouring and the application of prosthetic materials or bone grafts to achieve the desired aesthetic outcome. This dual approach not only reduces bony prominences but also addresses any asymmetry present in the frontal bone. The procedure may involve the use of bone cement or harvested bone grafts to fill in depressions and sculpt the frontal bone to restore symmetry. The use of autografts, typically harvested from the iliac crest, is also a critical component of this procedure, ensuring that the material used for reconstruction is biocompatible and effective in achieving the desired contour. Overall, this surgical intervention is designed to enhance the facial profile by creating a more balanced and aesthetically pleasing forehead contour.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 21138 is indicated for patients presenting with specific conditions related to the frontal bone. These indications include:
The surgical procedure for CPT® Code 21138 involves several detailed steps to ensure effective reduction and contouring of the forehead. The steps include:
Post-procedure care following forehead reduction surgery is crucial for optimal recovery and results. Patients can expect to experience some swelling and discomfort in the forehead area, which is typically managed with prescribed pain medications. It is important for patients to follow their surgeon's instructions regarding activity restrictions, wound care, and follow-up appointments. The skin and soft tissues are replaced over the frontal bone, and any excess skin is excised before the incision is closed in layers. Patients should be monitored for any signs of complications, such as infection or excessive bleeding, during the recovery period. Full recovery may take several weeks, during which time patients should avoid strenuous activities and follow a gradual return to normal routines as advised by their healthcare provider.
| Short Descr | RDCTJ FOREHEAD CNTRG&PROSTC | Medium Descr | RDCTJ FHD CNTRG & PROSTHETIC MATRL/BONE GRAFT | Long Descr | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 161 - Other OR therapeutic procedures on bone |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery |
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| 2025-01-01 | Changed | Short Description changed. |
| 2013-01-01 | Changed | Medium Descriptor changed. |
| 1991-01-01 | Added | First appearance in code book in 1991. |
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