Oral Surgery Coding & Reimbursement Alert

Published on Tue Jan 27, 2015 PDF

Question: Our maxillofacial surgeon is planning on performing masseter muscle reduction for a patient. I want to know what codes you will have to report for procedure and if the procedure is covered for reimbursement?

Nevada Subscriber

Answer: You have two codes to report the procedure, depending on the approach your surgeon uses during the surgery. If your oral surgeon used an extraoral approach, you report 21295 (Reduction of masseter muscle and bone [e.g., for treatment of benign masseteric hypertrophy]; extraoral approach). You report 21296 (…intraoral approach) if your surgeon employed an intraoral approach during the surgery.

The procedure is done to reduce the masseter muscle when there is a hypertrophy of the muscle. The procedure will not be covered if the sole purpose of the procedure was cosmetic. However, you can get reimbursement for the procedure if your surgeon performed the procedure for any of the following reasons:

• There is significant skeletal deformity caused because of the hypertrophy of the muscle.
• The hypertrophy of the muscle is causing speech difficulties
• There are problems with mastication and deglutition (swallowing) that are attributed to the hypertrophy of the masseter muscle
• The muscle hypertrophy is causing obstructive sleep apnea.

Reminder: Most payers that do provide coverage for the procedure might require you to obtain prior authorization or else you might not get reimbursed.