CPT 21026Surgery

Excision of facial bone(s)

CPT code 21026 covers the surgical removal of facial bone tissue, typically performed to treat bone lesions, tumors, infections, or deformities affecting the facial skeleton. This is a complex surgical procedure requiring precise documentation of the specific bone(s) removed and the surgical approach used.

Showing rates for

National Average

Base Medicare rate

$535.98

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

5.7

PE RVU (NF)

10.26

MP RVU

0.61

Total RVU

16.57

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Document specific facial bone(s) excised with precise anatomical terminology (mandibular body vs ramus, maxillary alveolus vs sinus wall, etc.)
Impact: Prevents downcoding to E/M services; ensures proper code selection versus 21025 or 21029-21034 which have different payment rates
Bill in non-facility setting when possible as payment difference is $105.45 higher ($535.98 vs $430.53)
Impact: Increases revenue by 24.5% for eligible ASC or office-based procedures versus hospital outpatient department
Include pathology report and pre-operative imaging in claim submission to establish medical necessity for bone excision
Impact: Reduces denial rate by 40-60% for procedures requiring prior authorization or those flagged for medical review
When bilateral excision is performed, use modifier 50 rather than billing two units, as many payers reject unit-based billing for this code
Impact: Ensures proper payment of approximately $804 versus risk of complete denial or payment for single side only
Separate bone excision (21026) from any reconstruction codes (21141-21145, 21210, etc.) with clear documentation of distinct procedures
Impact: Prevents bundling; reconstruction codes add $800-$3,500 in additional reimbursement when properly documented as separate procedures
For extensive excisions requiring modifier 22, submit with cover letter quantifying additional time (typically >50% beyond usual) and complexity factors
Impact: Successful modifier 22 appeals can increase payment by $100-$150 but require peer review documentation

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 21026 in 2025?

The 2025 Medicare national average reimbursement for CPT 21026 is $535.98 in non-facility settings and $430.53 in facility settings. The code has a work RVU of 5.7 and total RVU of 16.57, calculated using the 2025 conversion factor of 32.3465.

What is the difference between CPT 21026 and 21025?

CPT 21025 covers excision of bone (e.g., for osteomyelitis or bone abscess) in the facial area with a lower complexity, while 21026 specifically describes excision of facial bone(s) with greater anatomical complexity. Code selection depends on the specific bone excised, extent of surgery, and operative approach documented in the operative report.

Can CPT 21026 be billed with facial reconstruction codes?

Yes, CPT 21026 can be billed with facial reconstruction codes (21141-21145, 21210, etc.) when the excision and reconstruction are distinct procedures performed at different anatomical sites or the excision is extensive enough to require separate reconstruction. Use modifier 59 or XS to indicate a distinct procedural service and ensure documentation clearly separates the two procedures.

What documentation is required to bill CPT 21026?

Required documentation includes the specific facial bone(s) excised with precise anatomical location, medical necessity with supporting diagnosis, detailed surgical approach and technique, measurements of bone removed, pathology disposition, and any complexity factors. Pre-operative imaging and pathology reports significantly reduce denial risk.

Does CPT 21026 require prior authorization from Medicare or commercial payers?

Medicare typically does not require prior authorization for 21026, but many Medicare Advantage and commercial payers do require pre-certification for facial bone excision as it is considered an elective surgical procedure. Always verify payer-specific requirements 7-10 days before scheduled surgery to avoid denials.

How do I bill CPT 21026 for bilateral facial bone excision?

For bilateral excision of identical facial bones (such as both zygomas or bilateral mandibular lesions), append modifier 50 to CPT 21026. This typically results in 150% payment of the base rate. Do not bill two separate line items or use two units, as most payers will deny duplicate billing without the bilateral modifier.

What are common denial reasons for CPT 21026 and how can they be prevented?

Common denials include lack of medical necessity documentation, bundling with reconstruction procedures, missing prior authorization, and incorrect code selection. Prevent denials by submitting pre-operative imaging, pathology reports, obtaining authorization when required, using appropriate modifiers (59 for distinct procedures), and ensuring operative reports clearly describe the specific facial bone excised and surgical complexity.