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The CPT® Code 21030 refers to the excision of a benign tumor or cyst located in the maxilla or zygoma, which are bones in the facial structure. This procedure is performed through a technique known as enucleation and curettage. Enucleation involves the careful removal of the tumor or cyst in its entirety, while curettage refers to the scraping of the tissue to ensure that all remnants of the tumor are eliminated from the surrounding bone. The procedure can be approached in two ways: externally or internally. In an external approach, the physician makes an incision on the outer surface of the face, allowing for direct access to the tumor. This method requires careful dissection of the surrounding tissue to reach the tumor. Conversely, the internal approach involves making an incision within the oral cavity, which provides access to the tumor without visible scarring on the face. Regardless of the approach taken, the goal is to remove the tumor intact, ensuring that it is completely excised from the maxilla or zygoma. After the tumor is removed, the incision site is sutured closed to promote healing and minimize complications.
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The procedure described by CPT® Code 21030 is indicated for the removal of benign tumors or cysts that are located in the maxilla or zygoma. These conditions may present as asymptomatic masses or may cause symptoms such as swelling, pain, or functional impairment in the surrounding areas. The excision is typically performed when the tumor or cyst is diagnosed as benign and poses no risk of malignancy, yet requires removal due to its size, location, or associated symptoms.
The procedure for excising a benign tumor or cyst from the maxilla or zygoma involves several key steps, which can vary depending on the chosen approach—external or internal.
Following the excision of a benign tumor or cyst, patients are typically monitored for any immediate complications. Post-procedure care may include instructions for pain management, wound care, and dietary modifications if an internal approach was used. Patients are advised to avoid strenuous activities and follow up with their physician to ensure proper healing and to monitor for any signs of recurrence or complications. The expected recovery time can vary based on the individual and the extent of the procedure, but most patients can anticipate a gradual return to normal activities within a few weeks.
| Short Descr | EXCISE MAX/ZYGOMA B9 TUMOR | Medium Descr | EXC BENIGN TUMOR/CYST MAXL/ZYGOMA ENCL & CURTG | Long Descr | Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage | 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) | 1 - Statutory 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 | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 142 - Partial excision bone |
| 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. | RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | 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). | 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. | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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.) | 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.) | 99 | Multiple modifiers: under certain circumstances 2 or more modifiers may be necessary to completely delineate a service. in such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. | GA | Waiver of liability statement issued as required by payer policy, individual case | 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 | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2003-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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