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The procedure described by CPT® Code 21049 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 a more extensive surgical approach. The term "extra-oral osteotomy" refers to the surgical cutting of bone from outside the mouth, which is required in this case to effectively remove the tumor or cyst along with a portion of the maxilla. The procedure may also involve a partial maxillectomy, which is the surgical removal of part of the maxilla. The physician may choose between an intraoral approach, where an incision is made inside the mouth, or an extraoral approach, where an incision is made outside the mouth. The choice of approach depends on the location and extent of the lesion. After the tumor is excised, the surgical site may require packing and closure, and in some cases, a bone graft may be necessary to support the structure of the maxilla. The final step involves suturing the incisions in layers to promote proper healing.
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The procedure 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 area of the maxilla, necessitating surgical intervention to prevent further complications or damage to surrounding structures.
The procedure begins with the selection of the surgical approach, which may be intraoral or extraoral, depending on the location and extent of the tumor or cyst.
Post-procedure care involves monitoring the surgical site for signs of infection or complications. Patients may be advised to follow specific oral hygiene practices to maintain cleanliness in the area. Pain management may be necessary, and the physician may prescribe analgesics to alleviate discomfort. Follow-up appointments are essential to assess healing and determine if any further interventions, such as additional imaging or treatments, are required. The recovery period may vary depending on the extent of the surgery and the individual patient's healing response.
| Short Descr | EXCIS UPPR JAW CYST W/REPAIR | Medium Descr | EXC B9 TUM/CST MAXL XTR-ORAL OSTEOT&PRTL MAXLC | Long Descr | Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (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) | 2 - Payment restriction for assistants at surgery does not apply 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 | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 142 - Partial excision bone |
| 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. | 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. | 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 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.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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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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