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Official Description

Osteoplasty, facial bones; reduction

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 21209 refers to osteoplasty of the facial bones, specifically focusing on the reduction of these bones. Osteoplasty is a surgical procedure that involves reshaping or reconstructing bone, and in this case, it pertains to the facial skeleton. The physician performs this procedure to correct deformities or excess bone that may be causing functional or aesthetic issues. During the operation, an incision is made over the affected area of the facial bone. The surgeon then utilizes specialized instruments such as saws or drills to carefully remove portions of the bone that are deemed excessive or deformed. This meticulous approach aims to restore the normal contour and function of the facial structure. After the necessary adjustments are made, the incisions are closed, ensuring that the surgical site is properly sealed to promote healing and minimize complications.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure of osteoplasty for facial bones, as indicated by CPT® Code 21209, is performed for various reasons related to the structural integrity and appearance of the facial skeleton. The following conditions may warrant this surgical intervention:

  • Facial Deformities - Conditions that result in abnormal shapes or sizes of the facial bones, which may affect both aesthetics and function.
  • Trauma - Injuries to the facial bones that lead to fractures or misalignments requiring surgical correction.
  • Congenital Anomalies - Birth defects that affect the development of facial bones, necessitating surgical intervention to improve appearance and function.
  • Bone Overgrowth - Excessive growth of bone tissue that can lead to discomfort, functional impairment, or cosmetic concerns.

2. Procedure

The osteoplasty procedure for facial bones involves several critical steps to ensure effective reduction and reshaping of the bone structure. The following outlines the procedural steps involved:

  • Step 1: Anesthesia Administration - The procedure begins with the administration of anesthesia to ensure the patient is comfortable and pain-free during the surgery. This may involve local anesthesia or general anesthesia, depending on the extent of the procedure and the patient's needs.
  • Step 2: Incision Creation - Once the patient is adequately anesthetized, the surgeon makes a precise incision over the area of the facial bone that requires reduction. The location and length of the incision are determined based on the specific bones being addressed and the extent of the deformity.
  • Step 3: Bone Removal - Utilizing specialized surgical instruments such as saws or drills, the surgeon carefully removes portions of the excess or deformed bone. This step requires precision to ensure that only the necessary bone is removed while preserving the surrounding structures and maintaining the integrity of the facial skeleton.
  • Step 4: Closure of Incisions - After the desired bone reduction has been achieved, the surgeon meticulously closes the incisions using sutures or other closure techniques. This step is crucial for promoting proper healing and minimizing the risk of infection or complications.

3. Post-Procedure

Following the osteoplasty procedure, patients can expect a recovery period that may involve specific post-operative care instructions. It is essential to monitor the surgical site for any signs of infection or complications. Patients are typically advised to avoid strenuous activities and follow a prescribed regimen for pain management. Follow-up appointments will be necessary to assess healing and ensure that the facial structure is recovering as intended. The overall recovery time may vary based on the extent of the procedure and the individual patient's healing process.

Short Descr REDUCTION OF FACIAL BONES
Medium Descr OSTEOPLASTY FACIAL BONES REDUCTION
Long Descr Osteoplasty, facial bones; reduction
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) 0 - Co-surgeons not permitted for this procedure.
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 Surgical procedure on ASC list in CY 2007; 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 142 - Partial excision 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).
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
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.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
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
GW Service not related to the hospice patient's terminal condition
KX Requirements specified in the medical policy have been met
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
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