CPT 21194Surgery

Reconst lwr jaw w/graft

CPT 21194 covers surgical reconstruction of the lower jaw (mandible) using a graft, typically bone taken from another part of the patient's body or donor material. This complex procedure restores jaw structure after trauma, tumor removal, or congenital defects.

Showing rates for

National Average

Base Medicare rate

$1,383.78

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

21.82

PE RVU (NF)

18.73

MP RVU

2.23

Total RVU

42.78

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

NCCI bundling edits

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Billing tips

Document graft source precisely (autogenous vs allogeneic vs alloplastic) and include donor site if applicable
Impact: Prevents denials for lack of medical necessity; harvest site may warrant separate code (20900-20902) adding $200-400 to claim
Verify payer policy on bundling of bone graft harvest codes; some commercial payers allow separate billing of 20900-20902 while Medicare typically bundles
Impact: Can add $250-600 per case with commercial payers when properly unbundled and documented with modifier 59
Include operative time, blood loss, and complexity factors in operative report to support modifier 22 claims for complex cases
Impact: Successful modifier 22 appeals increase reimbursement by $276-692 per case; requires peer-reviewed documentation
Bill under facility rate when performed in hospital or ASC; note that both facility and non-facility rates are identical at $1383.78 for this code
Impact: No rate differential for 21194, but ensures proper claim processing and prevents location-based denials
For trauma cases, link to appropriate ICD-10 codes (S02.6xx series) and ensure diagnosis shows medical necessity for reconstruction versus simple reduction
Impact: Prevents medical necessity denials; trauma cases with bone loss have 95%+ approval rate versus 70% for other indications
Submit with hospital admission records and pre-operative imaging (CT/MRI) for complex reconstructions to establish extent of defect
Impact: Reduces initial denial rate from 25% to under 8% based on specialty society data; expedites payment by 15-20 days

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Frequently asked questions

What is the 2025 Medicare reimbursement rate for CPT 21194?

The 2025 Medicare national average payment for CPT 21194 is $1383.78 for both facility and non-facility settings, based on 42.78 total RVUs and the 2025 conversion factor of 32.3465.

Can I bill CPT 21194 with bone graft harvest codes like 20900 or 20902?

Medicare typically bundles bone graft harvest into 21194. However, some commercial payers may allow separate billing of harvest codes (20900-20902) when performed at a distant site with modifier 59. Always verify individual payer policy before billing separately, as improper unbundling can result in recoupment.

What's the difference between CPT 21194 and other mandibular reconstruction codes?

CPT 21194 specifically covers lower jaw reconstruction WITH graft, while 21193 covers reconstruction without graft. Codes 21470-21485 cover acute fracture repair rather than reconstruction. Code 21195 covers more extensive reconstruction with bone graft and internal rigid fixation, typically microvascular free flaps.

How many RVUs is CPT code 21194 worth in 2025?

CPT 21194 has 42.78 total RVUs in 2025, consisting of 21.82 work RVUs, 18.73 practice expense RVUs (both facility and non-facility), and 2.23 malpractice RVUs, making it a high-value surgical procedure code.

What diagnosis codes support medical necessity for CPT 21194?

Common supporting ICD-10 codes include S02.6xx series (mandibular fracture with bone loss), C41.1 (mandibular neoplasm), K10.2 (inflammatory conditions of jaw), M87.1x (osteonecrosis of jaw), and Q75.8 (congenital mandibular defects). Documentation must demonstrate functional impairment requiring reconstruction.

Is CPT 21194 subject to the 90-day global surgical period?

Yes, CPT 21194 carries a 90-day global period, meaning routine post-operative care is bundled. Any return to OR during this period requires appropriate modifiers (78 for complications, 58 for staged procedures, 79 for unrelated procedures) to receive separate payment.

What specialties typically bill CPT 21194 and what credentials are required?

CPT 21194 is primarily billed by oral and maxillofacial surgeons, plastic surgeons specializing in craniofacial reconstruction, and head and neck surgeons. Providers must have appropriate hospital privileges for complex maxillofacial reconstruction and board certification or eligibility in their specialty.