CPT 21049Surgery

Excis uppr jaw cyst w/repair

CPT 21049 covers the surgical removal of a cyst or bony lesion from the upper jaw (maxilla) along with reconstruction of the surgical site to restore proper jaw structure and function.

Showing rates for

National Average

Base Medicare rate

$1,124.04

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

19.32

PE RVU (NF)

13.26

MP RVU

2.17

Total RVU

34.75

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

NCCI bundling edits

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Billing tips

Document cyst dimensions in three planes (length, width, depth) and exact anatomic location within maxilla, including relationship to maxillary sinus, teeth, and infraorbital structures
Impact: Prevents medical necessity denials and supports modifier 22 claims; inadequate sizing documentation causes 40-50% of initial denials
Submit pathology report with claim showing histologic confirmation of cyst type (odontogenic keratocyst, dentigerous, radicular, etc.)
Impact: Reduces denial rate by approximately 35%; many payers require pathology confirmation for surgical excision codes
Separately document and code bone grafting materials if allogenic or xenogenic grafts used (consider +20900-20902 series)
Impact: Additional $200-600 reimbursement for graft material procurement depending on source and volume
Code the facility and professional components separately when performed in hospital or ASC setting; verify whether physician is employed or independent
Impact: Both facility and professional rates are $1124.04 for this code, but employment status affects who bills which component
Include pre-operative imaging reports (CT, panorex, CBCT) with medical necessity documentation showing cyst extent and surgical planning rationale
Impact: Decreases payer requests for additional documentation by 60%; expedites claim processing by 10-15 days on average
For Medicare patients, verify if procedure meets inpatient-only list requirements or can be performed in ASC; payment setting affects total reimbursement
While both rates equal $1124.04 for professional component, facility overhead and total case cost varies significantly by setting

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 21049 in 2025?

The 2025 Medicare national average reimbursement for CPT 21049 is $1124.04 for both facility and non-facility settings, based on 34.75 total RVUs and the 2025 conversion factor of 32.3465.

Can CPT 21049 be billed with tooth extraction codes on the same day?

Yes, but requires modifier 59 and clear documentation that the cyst excision extended significantly beyond the extraction socket into the maxillary bone and required separate surgical access and repair. The procedures must be distinct and separately identifiable to avoid bundling denials.

What documentation is required to support medical necessity for CPT 21049?

Required documentation includes pre-operative imaging showing cyst size and location, clinical symptoms or risk factors necessitating excision, cyst measurements in three dimensions, pathology report confirming diagnosis, and detailed operative report describing both excision and repair components.

How many RVUs is CPT 21049 worth in 2025?

CPT 21049 has 34.75 total RVUs consisting of 19.32 work RVUs, 13.26 practice expense RVUs (both facility and non-facility), and 2.17 malpractice RVUs according to the 2025 Medicare Physician Fee Schedule.

When should I use modifier 22 with CPT 21049?

Use modifier 22 when the cyst exceeds 3cm, involves multiple anatomic compartments (sinus, nasal cavity, orbital floor), requires extensive bone grafting, or presents unusual complexity requiring significantly increased operative time beyond the typical case. Include detailed documentation comparing to standard case complexity.

What specialty physicians typically bill CPT 21049?

CPT 21049 is primarily billed by oral and maxillofacial surgeons, followed by otolaryngologists (ENT surgeons), head and neck surgeons, and occasionally plastic surgeons with maxillofacial privileges. The provider must have appropriate surgical credentials and hospital privileges.

Does CPT 21049 include bone grafting or is that billed separately?

The descriptor 'with repair' includes basic bone work and closure, but significant bone grafting using allogenic, xenogenic, or autogenous grafts from distant sites may be separately billable using codes 20900-20902 or +15777 depending on graft source and technique. Documentation must justify the additional graft procedure as distinct from the included repair.