Crystal's MCW Coder Hub🧬 CPT Code 21390: Documentation & Billing Guide
Genioplasty, Augmentation or Reduction; Sliding Osteotomy or Inlay Graft
Last Updated: February 2026
Status: 2025 Medicare Fee Schedule Compliant
Specialty Tags:
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| Element | Details |
|---|---|
| Code | 21390 |
| Code Type | Surgical Procedure - Maxillofacial/Plastic Surgery |
| Procedure Type | Chin bone augmentation or reduction via sliding osteotomy or graft |
| Global Period | 090 days (major surgical procedure) |
| Work RVU (2025) | 5.87 RVU |
| Practice Expense RVU (2025, Non-Facility) | 3.18 RVU |
| Practice Expense RVU (2025, Facility) | 2.12 RVU |
| Malpractice RVU (2025) | 0.65 RVU |
| Total RVU (2025, Non-Facility) | 9.70 RVU |
| Total RVU (2025, Facility) | 8.64 RVU |
| 2025 Medicare Fee (Non-Facility) | ~32.3465 CF × GPCI) |
| 2025 Medicare Fee (Facility) | ~32.3465 CF × GPCI) |
| Conversion Factor (2025) | $32.3465 |
| Estimated Commercial Insurance | $900 - 1,500 |
| Global Period Includes | Pre-operative visits, surgery, post-operative visits (90 days) |
| Common Place of Service | Hospital inpatient (21), Hospital outpatient (22), ASC (24), Office OR (11) |
| Specialty | Oral & Maxillofacial Surgery, Plastic Surgery, Otolaryngology |
| Procedure Variations | Sliding osteotomy (most common) vs. inlay graft (less common) |
📋SHORT DEFINITION
CPT 21390 describes a genioplasty with augmentation or reduction using a sliding osteotomy or inlay graft technique. This surgical procedure modifies the chin (mentum) by either moving the chin bone forward/backward/vertically (sliding osteotomy) or by placing bone or synthetic material to augment the chin (inlay graft), used to correct chin prominence, recession, or asymmetry for functional or esthetic improvement.
LONG DEFINITION
CPT 21390 represents a surgical modification of the chin bone (mandibular symphysis) using one of two primary techniques:
Technique 1: Sliding Osteotomy (Most Common)
- Horizontal bone cut made at or below the lower border of the mandible in the chin region
- Chin segment mobilized and moved forward (advancement), backward (setback), or rotated vertically
- New position secured with rigid internal fixation (plates, screws)
- Soft tissue redraped around repositioned chin
- Used for: Chin advancement (microgenia), chin reduction (prognathism), vertical correction
Technique 2: Inlay Graft (Less Common)
- Bone graft material (autologous bone, allograft, or alloplast) placed directly into or onto the chin bone
- Graft shaped to desired contour and secured with plates or screws
- Soft tissue sutured over graft
- Used for: Augmentation without moving entire chin segment, when patient has adequate chin projection anteriorly but desires additional dimension
Common Clinical Indications:
For Augmentation (21390):
- Microgenia (underdeveloped or recessed chin)
- Horizontal deficiency in anterior-posterior dimension
- Asymmetric chin (one side deficient)
- Correction of skeletal Class II with anterior deficiency
- Correction after trauma (chin fracture malunion)
- Correction of sleep apnea (advancing chin for airway space)
- Esthetic improvement when combined with other orthognathic procedures
For Reduction (21390):
- Macrogenia (prominent, overdeveloped chin)
- Anterior prognathism (excessive forward projection)
- Vertical excess (long chin)
- Asymmetry (one side excessive)
Procedure Duration: Typically 1-2 hours
Key Distinctions:
- CPT 21120 = Genioplasty, augmentation (simple, autograft/allograft/prosthetic)—lower RVU (2.53)
- CPT 21121 = Genioplasty, sliding osteotomy, single piece—lower RVU (4.02)
- CPT 21122 = Genioplasty, sliding osteotomy, two or more pieces—moderate RVU (5.44)
- CPT 21390 = Genioplasty, augmentation/reduction; sliding osteotomy or inlay graft—highest RVU (5.87), most complex
Important Note:
CPT 21390 is the most comprehensive genioplasty code and includes complex sliding osteotomy or advanced graft augmentation. Most contemporary genioplasties use this code for standard sliding osteotomy procedures.
WORK RELATIVE VALUE UNITS (wRVUs) & COMPONENTS
Work RVU Breakdown (2025)
| RVU Component | Value | What It Represents |
|---|---|---|
| Work RVU | 5.87 | Physician work, technical skill, time, decision-making |
| Practice Expense RVU (non-facility) | 3.18 | Surgical instruments, implants, staff support |
| Practice Expense RVU (facility) | 2.12 | Lower due to hospital/ASC equipment overhead |
| Malpractice RVU | 0.65 | Malpractice insurance and liability (major surgery) |
| TOTAL RVU (non-facility) | 9.70 | Total relative value units |
| TOTAL RVU (facility) | 8.64 | Total relative value units (lower) |
RVU Conversion to Dollar Amount (2025)
Formula: RVU × Conversion Factor (CF) × Geographic Practice Cost Index (GPCI) = Payment
2025 Medicare Conversion Factor: $32.3465
Typical Calculations (Non-Facility, GPCI = 1.0):
- 5.87 wRVU × 189.93** (work component)
- 3.18 PE RVU × 102.88** (practice expense)
- 0.65 MP RVU × 21.03** (malpractice)
- Total = ~$313.96 per procedure (non-facility, GPCI 1.0)
Facility-Based (Hospital/ASC):
- 5.87 wRVU × 189.93** (work component, same)
- 2.12 PE RVU × 68.61** (practice expense, lower)
- 0.65 MP RVU × 21.03** (malpractice, same)
- Total = ~$279.47 per procedure (facility, GPCI 1.0)
Real-World Range (2025):
- Non-Facility (Office OR or Hospital): 365 (depending on GPCI)
- Facility-Based (Hospital OR, ASC): 325 (lower PE RVU)
GLOBAL PERIOD
Global Period Status: 090 days (90-Day Global Period)
What This Means:
- CPT 21390 is a major surgical procedure with a 90-day global period
- Includes ALL pre-operative and post-operative care:
- All office visits within 90 days before surgery
- The surgery itself
- All post-operative visits within 90 days (routine follow-up, wound checks, etc.)
- Hospital care related to the procedure
- Post-operative complications related to the surgery
- One flat fee covers all bundled services
- Separate payment only for unrelated E/M during global period (use modifier -24)
Billing Implications:
- Cannot bill separate office visit codes within 90 days of surgery for related care - included in global fee
- CAN bill separate codes for unrelated problems during global period with modifier -24 (unrelated E/M)
- CAN bill separate codes for additional procedures performed same day with modifier -59 (distinct procedural service)
- Global period does NOT include costs for hospitalization; hospital bills separately for facility charges
Global Period Timeline:
- Pre-operative period: Day before surgery through surgery date
- Post-operative period: Day of surgery through 90 days after surgery
DOCUMENTATION REQUIREMENTS FOR 21390
Minimum Documentation Components
Pre-Operative Assessment:
- Chief Complaint/Indication: Chin deficiency/prominence, malocclusion, esthetic concern, functional impairment
- History: Duration of concern, prior surgeries, trauma history
- Physical Examination:
- Chin projection (anterior-posterior dimension)
- Vertical dimension (height relative to other facial features)
- Symmetry (asymmetry documentation)
- Occlusal relationship (if relevant to jaw surgery)
- Soft tissue contour
- Imaging: Lateral cephalometric radiographs (showing B-point, Pog, gnathion), CT scan if available
- Informed consent: Documentation of risks (nerve injury, infection, asymmetry, need for revision), benefits, alternatives (implants vs. surgery, conservative approach)
- Baseline photographs: Frontal, lateral, oblique views (standard of care)
Surgical Procedure Documentation:
- Technique: Sliding osteotomy (advancement, setback, rotation) vs. inlay graft
- Approach: Intraoral approach documented
- Bone cuts: Location of horizontal/vertical cuts, extent, bilateral vs. unilateral
- Mobilization: Chin segment mobilized and movement confirmed
- Repositioning: Direction (forward mm, backward mm, rotated degrees, raised/lowered mm)
- Fixation: Type (plates, screws, number, location, bilateral confirmation)
- Graft (if applicable): Type (autologous, allograft, alloplast), source, location, shape, amount
- Soft tissue management: Mentalis muscle repositioning, closure technique
- Intraoperative monitoring: Nerve function testing if performed (mental nerve, marginal mandibular nerve)
- Intraoperative complications: None vs. specific issues (nerve injury, vascular injury, fracture)
- Operative time: Total time
- Estimated blood loss: Important for post-op management
Post-Operative Plan:
- Occlusion: Final tooth contact (if jaw surgery performed)
- Dietary restrictions: Soft diet for [X] weeks
- Activity restrictions: When patient can resume exercise, contact sports
- Swelling/Bruising: Expected timeline
- Medications: Pain management, antibiotics, other medications
- Followup Schedule: Post-op appointments (typically day 1, week 1, week 3, 6 weeks, 3 months, 6 months)
- Implant/Hardware: If implant used, any precautions
Post-Operative Notes (Included in Global Period):
- Wound status: Healing, swelling, ecchymosis, drainage
- Chin contour: Assessment of final position, symmetry
- Soft tissue motion: Mentalis movement (if applicable)
- Sensation: Mental nerve function, numbness extent
- Complications: None vs. specific issues
- Implant position: If appliances used, confirmation of stability
BILLING RULES & GLOBAL PERIOD MANAGEMENT
Global Period Coverage (CRITICAL)
What’s Included in the 90-Day Global Fee:
✓ Included (NO separate billing):
- All pre-operative E/M visits
- The surgical procedure itself
- All post-operative office visits for related care
- Hospital/facility charges (though hospital bills separately)
- Routine post-operative complication management
- Suture removal
- Wound checks
- Post-operative radiographs related to surgery
✗ NOT Included (Can bill separately with appropriate modifier):
- Unrelated E/M during global period (use modifier -24)
- Unrelated procedures during global period (use modifier -24 or -59)
- Additional concurrent orthognathic procedures (e.g., 21315 - Lefort I Guide 1 same day)
- Implant removal or revision after global period
Modifiers for Global Period
| Modifier | Description | When to Use |
|---|---|---|
| -24 | Unrelated E/M during postoperative period | When billing E/M for unrelated problem during 90-day period |
| -59 | Distinct procedural service | When performing unrelated procedure same day |
| -LT/-RT | Left/Right side | For side-specific unilateral procedures (21390 is typically unilateral) |
| -50 | Bilateral procedure | If bilateral genioplasties (uncommon, requires two separate genioplasties) |
| None (most common) | Standard billing | Routine unilateral genioplasty |
Modifier -24 Usage (Unrelated E/M During Global):
- When: Patient returns during 90-day post-op period for unrelated problem (e.g., unrelated hypertension check, viral URI)
- Apply -24 to: The E/M code, not the 21390
- Example: Patient 3 weeks post-genioplasty returns for unrelated sore throat → Bill 99213-24
MEDICARE RULES FOR 21390
CMS-Specific Rules & Policies
1. Global Period Management (Critical)
- 90-day global period is standard
- All routine post-op care included in global fee
- Unrelated services must use modifier -24 to be separately billed
2. Facility vs. Non-Facility Billing
- Non-Facility (office-based OR): Higher PE RVU (3.18), higher reimbursement (~$314)
- Facility (hospital OR, ASC): Lower PE RVU (2.12), lower reimbursement (~$279)
- Facility bills separately for facility charges (hospital or ASC facility fee)
3. Graft Material Coding
- Bone graft (if used) is included in 21390 RVU
- Do NOT bill separately for graft material (CPT 20930-20938)
- Exception: Some payers may allow separate payment for graft HARVESTING from anatomically distant site with -59 modifier (verify policy)
4. Concurrent Orthognathic Procedures
- 21390 + 21315 - Lefort 1 Guide 2 (LeFort I) can be billed same day for combined jaw correction
- Both procedures payable; both have 90-day global periods
- Both codes billed with both RVU values
5. Assistant at Surgery
- Can bill assistant surgeon (modifier -80 or -81 or -82)
- Assistant typically paid 16-20% of primary surgeon fee
- For 21390, assistant would receive ~63 (16 - 20% of $314)
6. Local Coverage Determinations (LCDs)
- Most orthognathic procedures do not have specific NCDs
- Some MACs may have LCDs requiring pre-authorization
- Verify your MAC for specific requirements
LOCAL COVERAGE DETERMINATIONS (LCDs) & NATIONAL COVERAGE
National Coverage Determination (NCD)
There is NO specific NCD for CPT 21390.
General Medicare Coverage Policy:
- Genioplasty covered when performed for documented functional or medical necessity (not purely esthetic)
- Documentation must show:
- Functional impairment (eating, breathing, sleep apnea, speech)
- Or documented sleep apnea corrected by advancement
- Or significant asymmetry affecting function
- Purely esthetic cases not covered
Local Coverage Determinations (LCDs) - MAC-Specific
LCDs vary by Medicare Administrative Contractor (MAC) jurisdiction.
Common LCD Requirements for 21390:
| Requirement | Details |
|---|---|
| Medical Necessity | Functional impairment or sleep apnea; not purely esthetic |
| Documentation | Pre-operative imaging (cephalometric radiographs), photos, clinical assessment |
| Diagnosis Code | ICD-10 should reflect functional or medical indication (M26.8x for dental/skeletal problems, or sleep apnea code) |
| Concurrent Procedures | If combined with other orthognathic procedures (LeFort I, sagittal split), all must be justified |
| Prior Authorization | Some MACs require pre-auth for orthognathic procedures |
| Surgeon Credentials | Board certification or specialty training preferred but not always required |
To Find Your MAC’s LCD:
- Go to CMS LCD Search Tool: https://www.cms.gov/cclc/lcd
- Enter your MAC jurisdiction
- Search for “genioplasty,” “mandibular advancement,” or “orthognathic”
- Review specific coverage criteria and authorization requirements
COMMON MODIFIERS & GLOBAL PERIOD RULES
Modifier -24 (Unrelated E/M During Post-Op Period)
Use when: Billing E/M for unrelated problem during 90-day global period
Example:
- Patient has genioplasty on 2/15/2026 (90-day global ends 5/15/2026)
- On 3/1/2026, patient develops unrelated hypertension and returns for management
- Coding: 99213-24 for hypertension (unrelated to genioplasty)
- The 21390 global fee remains unchanged; separate E/M payment applies
Documentation requirement: E/M note must clearly document unrelated problem
Modifier -59 (Distinct Procedural Service)
Use when: Performing unrelated procedure same day as 21390
Example:
- Patient undergoing genioplasty + rhinoplasty (nose surgery) same day
- These are distinct procedures
- Coding: 21390 + rhinoplasty code (e.g., 30400-59)
- Both procedures billed; both paid (if criteria met)
2025 REIMBURSEMENT INFORMATION
Medicare 2025 Fee Schedule
CPT 21390 - Genioplasty, Augmentation or Reduction
| Category | Value |
|---|---|
| Work RVU | 5.87 |
| Practice Expense RVU (non-facility) | 3.18 |
| Practice Expense RVU (facility) | 2.12 |
| Malpractice RVU | 0.65 |
| Total RVU (non-facility) | 9.70 |
| Total RVU (facility) | 8.64 |
| Conversion Factor (2025) | $32.3465 |
| National Average Fee (Non-Facility, GPCI 1.0) | $313.96 |
| Estimated Range (Non-Facility) | $290 - 365 |
| National Average Fee (Facility, GPCI 1.0) | $279.47 |
| Estimated Range (Facility) | $260 - 325 |
Year-Over-Year Comparison (2024 vs 2025)
| Metric | 2024 | 2025 | Change |
|---|---|---|---|
| Work RVU | 5.87 | 5.87 | — |
| PE RVU (non-facility) | 3.18 | 3.18 | — |
| CF | $33.2875 | $32.3465 | -2.8% |
| National Average (Non-Facility) | ~$323.37 | ~$313.96 | -2.8% |
| Global Period | 090 | 090 | — |
Reason for fee decrease: 2.8% conversion factor reduction due to expiration of temporary 2024 increase.
Commercial Insurance & Medicaid Reimbursement (2025)
Commercial Insurance:
- Typically pays 2-4× Medicare rates
- Estimated 21390 payment: 1,500 (varies by payer)
- Often requires pre-authorization
- Some payers cover only if functional impairment documented
Medicaid:
- Varies significantly by state
- Estimated 21390 payment: 600 (state-dependent)
- Many states do NOT cover genioplasty (considered esthetic)
- States that do cover require functional documentation
- Prior authorization typically required
Self-Pay/Cash Price:
- Typically 5,000 depending on provider, location, complexity
COMPARISON TO RELATED CODES
Genioplasty Code Family (21120-21390)
| Code | Description | Complexity | RVU (Work) | Global |
|---|---|---|---|---|
| 21120 | Genioplasty, augmentation (autograft, allograft, prosthetic) | Low-Moderate | 2.53 | 090 |
| 21121 | Genioplasty, sliding osteotomy, single piece | Moderate | 4.02 | 090 |
| 21122 | Genioplasty, sliding osteotomy, 2+ pieces | Moderate-High | 5.44 | 090 |
| 21390 | Genioplasty, augmentation/reduction; sliding osteotomy or inlay graft | High | 5.87 | 090 |
21390 vs 21120/21121/21122 (When to Use)
| Aspect | 21120 | 21121 | 21122 | 21390 |
|---|---|---|---|---|
| Technique | Simple implant/graft | Single-piece osteotomy | Multi-piece osteotomy | Advanced osteotomy or complex graft |
| RVU | 2.53 | 4.02 | 5.44 | 5.87 |
| Complexity | Simple | Moderate | Moderate-High | High |
| Indications | Mild augmentation, simple graft | Standard advancement/setback | Complex chin reshaping | Severe deficiency, complex movements |
| Modern Use | Less common | Less common today | Uncommon | Most common code today |
Clinical Note: Modern practice often uses 21390 for standard sliding osteotomy procedures because it encompasses broader scope. 21120-21122 used for simpler cases or specific payer requirements.
FREQUENTLY BILLED SCENARIOS FOR 21390
Scenario 1: Genioplasty for Microgenia (Chin Advancement)
Patient: 35-year-old with recessed chin, anterior deficiency, normal occlusion
Pre-Operative Assessment: Cephalometric radiographs show B-point to Pog angle deficient by 8mm. Lateral profile shows inadequate chin projection. Functional complaint: mild difficulty with chin positioning in sleep. Esthetic concern: profile imbalance.
Surgical Plan: Sliding osteotomy for chin advancement
Procedure: Intraoral approach. Horizontal osteotomy made below the lower border of the mandible at the level of the mentum. Chin segment mobilized and advanced 8mm anteriorly. Rigid internal fixation with two 2.0mm titanium plates positioned for stability. Mentalis muscle repositioned. Incisions closed.
Post-Op: Soft diet × 2 weeks, return to normal activity × 4 weeks. Sensation gradually returns over 3-6 months.
Coding:
- 21390 (genioplasty, chin advancement via sliding osteotomy)
- Diagnosis: M26.8 (other specified dentofacial anomalies), or esthetic indication depending on payer
- Note: If purely esthetic and no functional impairment documented, Medicare may not cover; verify payer
Scenario 2: Genioplasty for Sleep Apnea (Advancement)
Patient: 52-year-old with documented obstructive sleep apnea (OSA), failed CPAP tolerance
Pre-Operative Assessment: Sleep study confirmed moderate OSA (AHI 18). CPAP attempted but unable to tolerate. Cephalometric analysis shows deficient anterior mandible contributing to airway collapse. ENT evaluation shows no other upper airway obstruction.
Surgical Plan: Sliding osteotomy for chin advancement to expand airway space
Procedure: Horizontal osteotomy made in symphysis region. Chin advanced 8mm anteriorly. Rigid fixation applied. Soft tissue repositioning.
Post-Op: Post-operative sleep study scheduled 3 months post-op to assess improvement.
Coding:
- 21390 (genioplasty for airway improvement/OSA)
- Diagnosis: G47.33 (obstructive sleep apnea, moderate), or M26.8 (dentofacial anomaly contributing)
- Note: Medicare more likely to cover OSA indication vs. purely esthetic
Scenario 3: Genioplasty Combined with Orthognathic Surgery (21390 + 21315)
Patient: 28-year-old with Class III malocclusion + microgenia, maxillary hypoplasia
Surgical Plan: Combined LeFort I (maxillary advancement) + genioplasty (chin advancement)
Procedure: Both procedures performed in single operative session under same anesthesia.
- LeFort I: Maxilla advanced 6mm anteriorly
- Genioplasty: Chin advanced 5mm anteriorly (sliding osteotomy technique) Coding:
- 21315 (LeFort I maxillary osteotomy)
- 21390 (genioplasty, chin advancement)
- Both codes billed; both RVUs paid
- Both carry 90-day global periods (coincide)
- Diagnosis: M26.81 (anterior relation anomaly), M26.8 (maxillary deficiency), etc.
Scenario 4: Genioplasty Reduction (Macrogenia)
Patient: 42-year-old with prominent, overdeveloped chin (macrogenia)
Pre-Operative Assessment: Lateral cephalometric shows excessive Pog projection (>10mm anterior to normal), long vertical dimension. Esthetic concern: chin too prominent, profile imbalance.
Surgical Plan: Sliding osteotomy for chin reduction and vertical adjustment
Procedure: Horizontal osteotomy made at level of mentum. Chin segment mobilized and moved posteriorly 5mm (setback) and superiorly 3mm (vertical reduction). Rigid fixation applied. Soft tissue redraped.
Coding:
- 21390 (genioplasty, chin reduction via sliding osteotomy)
- Diagnosis: M26.8 (other dentofacial anomaly—macrogenia)
- Note: If purely esthetic and no functional impairment, payer may not cover; verify
Scenario 5: Genioplasty Revision During Global Period
Scenario: Original genioplasty performed 3 weeks ago. Patient returns noting asymmetry or inadequate correction.
Clinical Assessment: Revision needed to correct position or contour.
Coding Consideration:
- Original 21390: Global period active (90 days from original surgery)
- Revision genioplasty: May be billable as 21390-76 (repeat procedure by same physician) during global period
- OR as 21390-79 (unrelated procedure during post-op period) if truly separate issue
- Verify payer policy; some may deny revision during global period or pay reduced fee
- Pre-authorization recommended for revision procedures
DOCUMENTATION TIPS FOR 21390
What to Document
✓ SHOULD INCLUDE:
- Indication for Surgery - Chin deficiency/prominence, asymmetry, esthetic concern, functional impairment (sleep apnea, eating, speech)
- Pre-Operative Measurements:
- Cephalometric analysis (B-point to Pogonion distance, vertical dimension, etc.)
- Clinical assessment (anterior-posterior deficiency mm, vertical excess/deficiency mm)
- Symmetry assessment (asymmetry mm)
- Imaging - Cephalometric radiographs, CT scan if available
- Baseline Photographs - Frontal, lateral, oblique views
- Physical Examination - Chin projection, vertical dimension, symmetry, occlusal relationship, soft tissue contour
- Surgical Technique - Sliding osteotomy (most common) or inlay graft (if used)
- Approach - Intraoral approach documented
- Bone Cuts - Location, extent, bilateral confirmation
- Repositioning Data:
- Direction of movement (forward mm, backward mm, rotated degrees, raised/lowered mm)
- Final position documented
- Fixation - Type (plates, screws), number, location, bilateral confirmation
- Graft (if applicable): Type (autologous, allograft, alloplast), source, amount, location
- Soft Tissue Management - Mentalis muscle repositioning, closure technique
- Intraoperative Monitoring - Nerve function assessment, mental nerve visualization
- Intraoperative Complications - None vs. specific issues (nerve injury, fracture, vascular injury)
- Operative Time - Total time in OR
- Estimated Blood Loss - Important for post-op management
- Post-Operative Instructions - Dietary restrictions, activity limitations, medications, followup schedule
- Post-Operative Notes (Global Period) - Wound healing, chin contour, sensation, complications, implant stability
✗ SHOULD AVOID:
- Vague descriptions (“osteotomy performed” without specifics on direction, amount)
- Missing pre-operative measurements (no cephalometric data, no assessment of deficiency/excess)
- Incomplete surgical details (which cuts, fixation type/location?)
- No documentation of post-operative position (final result description)
- Copy-paste documentation without procedure-specific details
- Missing baseline photos
Sample Operative Note Template
OPERATIVE REPORT - Genioplasty (21390)
PATIENT: [Name], Age [X]
DATE OF PROCEDURE: [Date]
SURGEON: [Name, Credentials]
ANESTHESIA: General endotracheal anesthesia
INDICATION:
Patient is a [X]-year-old with [chin deficiency/prominence/asymmetry] [with/without functional impairment]. Cephalometric analysis shows [specific measurements: B-point to Pog [X]mm deficient/excessive, vertical dimension [X]mm, etc.]. Patient desires [advancement/reduction/asymmetry correction] for [functional improvement/esthetic balance/sleep apnea management].
PRE-OPERATIVE FINDINGS:
- Cephalometric analysis: [Specific measurements and comparison to normal values]
- Panoramic radiographs: [Findings]
- CT scan: [If obtained; specific findings]
- Clinical exam: [Chin projection deficiency/excess mm, symmetry status, vertical dimension assessment]
- Baseline photographs: Frontal, lateral, oblique views obtained
SURGICAL TECHNIQUE:
Patient positioned supine, prepped and draped in sterile fashion. General anesthesia induced. Endotracheal tube placed.
Approach: Intraoral incision made in the superior sulcus region, extending bilaterally to reflect soft tissue and expose the anterior mandible/symphysis region.
Osteotomy: Horizontal osteotomy cut made [at level of mentum / below lower border of mandible] using [rotary saw / oscillating saw / reciprocating saw]. Cut extended bilaterally from canine to canine region. Soft tissue at inferior border carefully protected.
Mobilization: Chin segment mobilized with [osteotome / lever] and confirmed to be completely mobile and separated from base.
Repositioning: Chin segment moved [forward X mm / backward X mm / rotated X degrees / elevated X mm] to achieve desired anterior-posterior projection and vertical position. Final position verified against pre-operative surgical plan.
Fixation: Rigid internal fixation applied using [2-4] titanium [L-plates / hybrid plates / other] with [screw count] 2.0mm screws placed bilaterally [specify locations]. Fixation confirmed stable with manipulation.
Soft Tissue Management: Mentalis muscle [repositioned / reattached] to maintain normal muscle function and soft tissue contour. [Pterygomasseter attachment / other soft tissue] adjusted as needed.
Hemostasis: Complete hemostasis achieved using cautery and local hemostatic agents.
Closure: Intraoral incisions closed in [layers] with [suture type] in [technique].
Complications: [None / specific complication with management].
Operative Time: [X] hours
Estimated Blood Loss: [X] mL
POST-OPERATIVE PLAN:
- Soft diet for [X] weeks.
- No hard, crunchy, or sticky foods.
- Pain management with [specific medications].
- Antibiotics: [Type] for [duration].
- Monitor for signs of infection, excessive swelling, or asymmetry.
- Postoperative follow-up: [Schedule specific dates].
- Expect swelling to peak at 48 hours, gradual reduction over 2-3 weeks.
- Sensation gradual return over 3-6 months.
AUDIT DEFENSE CHECKLIST FOR 21390
Before billing 21390, verify:
- Medical necessity documented - Functional impairment or medical indication (sleep apnea); not purely esthetic
- Cephalometric analysis documented - Specific measurements showing deficiency/excess (mm from normal)
- Pre-operative photographs obtained - Lateral, frontal, oblique views as baseline
- Imaging documented - Cephalometric radiographs, CT if obtained
- Surgical technique clearly described - Sliding osteotomy (most common) or inlay graft specified
- Bone cuts documented - Location, extent, bilateral confirmation
- Repositioning documented - Direction and amount of movement (mm forward/back, rotated degrees, etc.)
- Fixation documented - Type (plates, screws), number, bilateral locations
- Mentalis repositioning documented - Soft tissue management documented
- Intraoperative complications documented - Or note “none”
- Operative time documented - Total time in OR
- Estimated blood loss documented - Important for post-op planning
- Post-operative position assessed - Chin contour, symmetry, soft tissue appearance
- No separate billing during global period - Only 21390 billable for related care during 90 days (except unrelated with -24)
- Proper modifiers used - -24 if unrelated E/M during global, -59 if distinct procedure same day
- Diagnosis code supports indication - ICD-10 shows functional/medical necessity, not just esthetic intent
RED FLAGS FOR AUDITORS
21390 claims are at audit risk if:
- ❌ Indication appears purely esthetic (no functional impairment documented)
- ❌ Pre-operative cephalometric analysis missing or incomplete (no measurements of deficiency/excess)
- ❌ Surgical technique vague (direction/amount of movement not specified)
- ❌ Fixation details incomplete (type, number, locations?)
- ❌ Bone graft billed separately (20930-20938) when 21390 used (graft included in 21390)
- ❌ Post-operative E/M billed as separate codes during global period without -24 modifier
- ❌ Documentation copy-pasted without procedure-specific details
- ❌ Diagnosis code unrelated to procedure (esthetic surgery with E/M diagnosis)
- ❌ No baseline photography (may suggest inadequate pre-operative planning)
- ❌ Concurrent procedures billed without clear medical justification (21390 + LeFort I need clear functional indication)
MEDICARE RULES & RESTRICTIONS
Who Can Bill 21390?
Qualified Providers:
- DDS/DMD: Oral and maxillofacial surgeon (specialty trained and board certified preferred)
- MD: Plastic surgeon, otolaryngologist with maxillofacial surgery training
- DO: Same specialties as MD
Credentialing Requirements:
- License to practice dentistry (DDS/DMD) or medicine (MD/DO)
- Active provider number with Medicare
- Surgical privileges at hospital or ASC (if performing in those settings)
- Specialty training in oral/maxillofacial or plastic surgery
RHC/FQHC Restrictions
If provider is employed by RHC or FQHC:
- 21390 is NOT typically performed in RHC/FQHC settings (requires OR)
- If billed by facility, payment goes to facility’s all-inclusive rate
- Individual provider cannot bill separately
Assistant at Surgery & Co-Surgery
Assistant at Surgery (Modifier -80, -81, -82):
- Assistant can be billed separately using appropriate modifier
- Typical payment: 16-20% of primary surgeon fee
- Example: If 21390 pays 50 - $63
COMPLIANCE & CODING EXAMPLES
Appropriate 21390 Use Cases ✓
- Chin advancement (microgenia) - Recessed chin with objective cephalometric deficiency
- Sleep apnea treatment - Chin advancement improving airway space in OSA
- Functional malocclusion - Chin position affecting chewing or bite
- Asymmetric chin - Documented asymmetry with functional or significant esthetic impact
- Combined orthognathic surgery - Genioplasty + LeFort I or sagittal split for comprehensive jaw correction
- Trauma sequelae - Chin malposition after fracture healing; surgical correction for function/esthetics
- Cleft palate sequelae - Chin position abnormality in cleft patient after primary reconstruction
Inappropriate 21390 Use (Risks) ✗
- ❌ Purely esthetic surgery - No functional impairment documented, only esthetic desires
- ❌ No cephalometric analysis - Surgery billed without objective measurements of deficiency/excess
- ❌ Missing baseline photography - No documentation of pre-operative appearance
- ❌ Bone graft billed separately - Using both 21390 + bone graft codes when graft included in 21390
- ❌ Post-operative E/M billed during global period - Separate E/M coded for related post-op care during 90-day global
- ❌ Inadequate surgical documentation - Vague operative notes without specific measurements, fixation details
FREQUENTLY ASKED QUESTIONS (FAQs)
Q: When should I use 21390 vs. 21121 or 21122?
A: 21390 is the most comprehensive code for sliding osteotomy genioplasty. 21121/21122 are older/simpler codes. Modern practice typically uses 21390. Verify your payer’s preference.
Q: Can I bill 21390 for purely esthetic chin augmentation?
A: Depends on payer. Medicare typically requires functional indication (sleep apnea, eating, speech impairment) or medical necessity. Purely esthetic cases may not be covered. Verify your payer’s policy.
Q: Should I bill 21390 if I use an implant instead of osteotomy?
A: No. Implant-based augmentation typically uses 21120 (simpler genioplasty code), not 21390. 21390 is for osteotomy (bone-cutting) or complex graft procedures.
Q: Is bone graft included in 21390?
A: Yes. If bone graft is used (autologous, allograft), it is included in 21390 RVU. Do NOT bill separately (20930-20938).
Q: Can I bill post-operative visit codes during the 90-day global period?
A: NO, for related care. Post-operative visits for wound checks, swelling assessment, etc., are included in global fee. You can only bill separate E/M with modifier -24 if the visit addresses an unrelated problem.
Q: Can I bill 21390 + 21315 (LeFort I) same day?
A: Yes. These are distinct procedures (chin + maxilla), both billable with both RVU values. Both included in same anesthesia/operative session. Both carry 90-day global periods.
Q: What if I need to revise the genioplasty during the 90-day global period?
A: Revision during global period may be billed as 21390-76 (repeat procedure) or 21390-79 (unrelated procedure). Verify payer policy; many may deny revision or pay reduced fee during active global period. Pre-authorization recommended.
Q: Does the global period include orthodontist follow-up?
A: No. If orthodontist is involved in pre-operative planning or post-operative management, orthodontist bills separately for their services. Global period only covers surgeon’s services.
REAL-WORLD BILLING TIPS
Tips to Maximize Compliance & Revenue
- Document medical necessity clearly - Functional impairment, cephalometric measurements, or sleep apnea indication all strengthen claim
- Obtain pre-authorization - Recommended for genioplasty, especially if esthetic component suspected
- Obtain baseline photography - Lateral, frontal, oblique photos document pre-operative status and support medical necessity
- Include cephalometric analysis - Objective measurements of deficiency/excess are critical documentation
- Do NOT bill graft separately - Common error: billing 20930 + 21390 results in denial; graft included
- Manage global period correctly - Don’t code separate E/M for related post-op care during 90 days
- Use -24 modifier appropriately - Separate unrelated problems during global period with -24 on E/M
- Document surgical repositioning specifics - Amount and direction of movement critical for justification
- Keep operative report detailed - Pre-operative measurements, surgical technique, fixation details, post-operative position all important
- Coordinate with other specialists - If combined with orthodontist, ENT, or other specialists, clarify scope of surgical vs. non-surgical services
BILLING & CODING RESOURCES
Recommended Resources:
- AMA CPT Manual 2025 - Official CPT code definitions
- CMS Fee Schedule Database: https://www.cms.gov/medicare/physician-fee-schedule
- MAC LCDs: https://www.cms.gov/cclc/lcd (search for “genioplasty” or “orthognathic”)
- American Association of Oral and Maxillofacial Surgeons (AAOMS): https://www.aaoms.org (coding resources)
- American Society of Plastic Surgeons (ASPS): https://www.plasticsurgery.org (coding guidance)
- Your payer’s provider manual - Payer-specific coverage requirements
SUMMARY TABLE
| Element | Details |
|---|---|
| Official Definition | Genioplasty, augmentation or reduction; sliding osteotomy or inlay graft |
| Global Period | 090 days (major surgical procedure) |
| Work RVU (2025) | 5.87 |
| Total RVU (2025, Non-Facility) | 9.70 |
| Medicare Payment (2025, Non-Facility) | ~$314 |
| Medicare Payment (2025, Facility) | ~$279 |
| Typical Time | 1-2 hours |
| Provider Required | OMFS, plastic surgeon, ENT (specialty training preferred) |
| Common Modifiers | -24 (unrelated post-op E/M), -59 (distinct procedure), none (routine) |
| Typical Use | Chin advancement, reduction, sleep apnea, asymmetry correction |
| Common Mistakes | Missing medical necessity documentation; graft billed separately; global period violations; inadequate pre-operative measurements |
| Audit Risk | Moderate (medical necessity and documentation critical) |
| Bundling | Includes bone graft; do NOT bill separately |
| Telehealth Allowed | No (surgical procedure requires in-person) |
Document Created: February 2026
Compliant with: 2025 Medicare Physician Fee Schedule, CMS National and Local Coverage Determinations, AAOMS Coding Guidelines
Last Updated: February 2026