© Copyright 2025 American Medical Association. All rights reserved.
Forehead reduction surgery, specifically described by CPT® Code 21139, is a surgical procedure aimed at reducing and reshaping a prominent or asymmetrical frontal bone in the forehead area. This procedure is particularly indicated for patients with large brow bones resulting from overgrowth of the underlying frontal sinus. 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. This exposure is crucial for the subsequent steps of contouring and reshaping the bone. Unlike other related procedures, such as those coded under 21137 and 21138, which focus on contouring alone or contouring combined with the use of prosthetic materials or bone grafts, the procedure associated with CPT® Code 21139 involves not only contouring but also the setback of the anterior frontal sinus wall. This means that the frontal table of the frontal sinus is removed, reshaped, and repositioned in a flatter, more recessed position, which is then secured using internal fixation. The final steps involve replacing the skin and soft tissues over the newly contoured frontal bone, excising any excess skin, and meticulously closing the incision in layers to promote optimal healing and aesthetic outcomes.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 21139 is indicated for patients presenting with the following conditions:
The surgical procedure for CPT® Code 21139 involves several detailed steps to achieve the desired forehead reduction and contouring:
Post-procedure care for patients undergoing forehead reduction surgery includes monitoring for any signs of complications, such as infection or excessive swelling. Patients are typically advised to follow specific postoperative instructions, which may include keeping the surgical area clean and dry, avoiding strenuous activities, and attending follow-up appointments for assessment of healing. Recovery time can vary, but patients should expect some swelling and discomfort in the initial days following the surgery. Pain management may be prescribed as needed, and patients should be informed about the importance of adhering to the recommended care plan to ensure optimal recovery and aesthetic results.
| Short Descr | RDCTJ FOREHEAD CNTRG&SETBACK | Medium Descr | RDCTJ FHD CNTRG & SETBACK ANT FRONTAL SINUS WALL | Long Descr | Reduction forehead; contouring and setback of anterior frontal sinus wall | 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 |
| 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). | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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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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