CPT 21047Surgery

Excise lwr jaw cyst w/repair

CPT 21047 covers the surgical removal of a cyst from the lower jaw (mandible) along with repair of the bone and surrounding tissue. This procedure addresses benign growths that can weaken the jaw structure or cause pain and swelling.

Showing rates for

National Average

Base Medicare rate

$1,184.21

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

20.07

PE RVU (NF)

14.3

MP RVU

2.24

Total RVU

36.61

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

NCCI bundling edits

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Billing tips

Document cyst size, location, and extent of bone involvement in operative report
Impact: Proper documentation supports medical necessity and prevents denials; lack of specificity can trigger $1184.21 claim rejection
Submit pre-authorization with imaging (CT or panorex) showing cyst dimensions before scheduled procedure
Impact: Reduces denial rate by 60-70% for high-dollar surgical codes; many payers require prior authorization for reimbursement
Bill bone graft material separately with appropriate supply codes when allograft or synthetic materials used
Impact: Can add $200-$800 to total reimbursement depending on graft type and volume; use C1763 or HCPCS codes
Use modifier 22 with detailed documentation when cyst exceeds 3cm or requires complex reconstruction
Impact: Potential 20-40% payment increase ($237-$474 additional) but requires comparison to typical case complexity and extra time documentation
Verify facility vs non-facility status; this code has identical rates ($1184.21) but impacts total reimbursement picture
Impact: While Medicare rates are same, understanding setting affects facility fee billing and commercial payer negotiations
Do not separately bill pathology exam of cyst specimen; included in surgical package
Impact: Prevents unbundling denials and potential fraud flags; pathologist bills separately for their professional component

Applicable modifiers

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 21047 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 21047 is $1184.21 for both facility and non-facility settings. This is based on total RVUs of 36.61 multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary by geographic locality.

Does CPT 21047 require prior authorization from Medicare or commercial payers?

While Medicare typically does not require prior authorization for CPT 21047, many Medicare Advantage plans and commercial payers do require pre-authorization for this surgical procedure. Always verify specific payer requirements before scheduling, as lack of authorization is a common denial reason.

Can I bill CPT 21047 with a tooth extraction on the same day?

Yes, but documentation must clearly show the extraction is separate from the cyst excision procedure. If the tooth is involved in the cyst (as with dentigerous cysts), the extraction is typically considered inclusive. Use modifier 59 only when extraction is clearly a distinct, separate procedure at a different site.

What is the difference between CPT 21040 and 21047 for jaw cyst removal?

CPT 21040 covers excision of benign jaw tumors or cysts without bone reconstruction, while 21047 includes repair or reconstruction of the bone defect. Code 21047 has higher RVUs (36.61 vs lower for 21040) and is appropriate when bone grafting, significant repair, or reconstruction is performed as part of the procedure.

How many RVUs is CPT code 21047 worth in 2025?

CPT 21047 has 36.61 total RVUs in 2025, consisting of 20.07 work RVUs, 14.3 practice expense RVUs (both facility and non-facility), and 2.24 malpractice RVUs. This is a high-value surgical code reflecting the complexity and time required.

What documentation is required to support medical necessity for CPT 21047?

Required documentation includes pre-operative imaging showing the cyst with measurements, clinical examination findings, symptoms or functional impairment, pathology risk assessment, detailed operative report with cyst size and type, description of repair performed, and specimen submission to pathology. Lack of imaging is a frequent denial trigger.

Is CPT 21047 performed in a facility or office setting?

CPT 21047 is typically performed in a hospital outpatient department or ambulatory surgery center under general anesthesia, though the Medicare reimbursement rate is identical ($1184.21) for both facility and non-facility settings. The complexity and anesthesia requirements generally necessitate a surgical facility setting.