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The procedure described by CPT® Code 21048 involves the excision of a benign tumor or cyst located in the maxilla, which is the upper jawbone. This procedure is specifically indicated when the tumor or cyst is locally aggressive or destructive, necessitating an intra-oral osteotomy. In simpler terms, the physician will access the tumor through the mouth, making an incision in the muscle tissue to create a flap that can be reflected to expose the underlying structures. Once the tumor is located, it is carefully excised along with a portion of the surrounding bone to ensure complete removal and to minimize the risk of recurrence. In cases where an extraoral approach is required, the physician will make an incision outside the mouth, continuing to dissect through the tissue layers until the tumor is accessible for removal. This approach may also involve the excision of part of the maxilla itself. After the tumor is removed, the surgical site may be packed to control bleeding, and in some instances, a bone graft may be necessary to support the structural integrity of the maxilla. Finally, the incisions made during the procedure are sutured in layers to promote proper healing and minimize scarring.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 21048 is indicated for the excision of benign tumors or cysts of the maxilla that are characterized as locally aggressive or destructive lesions. These conditions may present symptoms such as swelling, pain, or functional impairment in the oral cavity, necessitating surgical intervention to prevent further complications or damage to surrounding tissues.
The procedure for excising a benign tumor or cyst of the maxilla using CPT® Code 21048 involves several critical steps to ensure effective removal and patient safety.
Post-procedure care following the excision of a benign tumor or cyst of the maxilla includes monitoring for any signs of infection, managing pain with prescribed medications, and following specific oral hygiene instructions to promote healing. Patients may be advised to avoid certain foods and activities that could disrupt the surgical site. Follow-up appointments are essential to assess healing and to remove sutures if non-dissolvable materials were used. The recovery period may vary depending on the extent of the surgery and the individual patient's healing response.
| Short Descr | REMOVE MAXILLA CYST COMPLEX | Medium Descr | EXC BENIGN TUMOR/CYST MAXL INTRA-ORAL OSTEOT | Long Descr | Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s]) | 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) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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 without MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 2 | 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. | 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). | RT | Right side (used to identify procedures performed on the right side of the body) | 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. | 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. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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 |
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| 2013-01-01 | Changed | Minor grammatical description change. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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