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The procedure described by CPT® Code 21296 involves the reduction of the masseter muscle and the underlying bone through an intraoral approach. This procedure is specifically indicated for the treatment of benign masseteric hypertrophy, a condition characterized by an abnormal enlargement of the masseter muscle, which is one of the primary muscles responsible for chewing. This hypertrophy can lead to a noticeable bulging at the mandibular angle, resulting in aesthetic concerns and potential functional issues. The intraoral approach distinguishes this procedure from similar interventions, such as those described in CPT® Code 21295, which utilizes an extraoral preauricular incision. During the procedure, an incision is made along the anterior edge of the mandibular ramus, allowing for direct access to the masseter muscle and the underlying bone. The surgical technique involves subperiosteal dissection, which is the careful separation of the tissue from the bone, followed by the detachment of the masseter muscle at its inferior posterior border. The procedure may also involve the use of a bur or saw to reduce any bony prominence at the mandibular angle, ensuring a more aesthetically pleasing contour. The masseter muscle is then resected and resized before being reattached to the mandible, and the incisions are subsequently closed, completing the surgical intervention.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 21296 is indicated for the treatment of benign masseteric hypertrophy, which is characterized by the following conditions:
The procedure for CPT® Code 21296 involves several key steps to effectively reduce the masseter muscle and the underlying bone:
Post-procedure care for patients undergoing the reduction of the masseter muscle and bone includes monitoring for any complications, managing pain, and ensuring proper healing of the surgical site. Patients may be advised to follow specific dietary restrictions to avoid excessive strain on the jaw during the initial recovery period. Follow-up appointments are typically scheduled to assess healing and the effectiveness of the procedure. Additional considerations may include physical therapy or exercises to restore normal function and mobility of the jaw as needed.
| Short Descr | REVISION OF JAW MUSCLE/BONE | Medium Descr | REDUCTION MASSETER MUSCLE & BONE INTRAORAL | Long Descr | Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach | 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) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies 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 |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
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