CPT 21245Surgery

Reconstruction of jaw

CPT code 21245 covers surgical reconstruction of the jaw, which may involve bone grafting, reshaping, or repositioning to restore jaw function and structure after trauma, cancer, congenital defects, or severe degeneration.

Showing rates for

National Average

Base Medicare rate

$1,180.32

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

13.12

PE RVU (NF)

22.02

MP RVU

1.35

Total RVU

36.49

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

NCCI bundling edits

Loading bundling edits…

Billing tips

Document complexity factors including extent of bone loss, number of segments involved, use of grafting materials (autogenous vs. alloplastic), and any microvascular techniques
Impact: Supports modifier 22 claims for additional reimbursement of 20-50% ($236-$590 additional) and reduces denial risk
Separately report bone graft harvesting procedures (20900-20902 series) when autogenous grafts are obtained from distant sites
Impact: Additional $300-$800 depending on harvest site and technique; commonly overlooked revenue opportunity
Verify facility vs. non-facility status before billing; the $259.74 difference between settings significantly affects revenue expectations
Impact: Ensures accurate payment posting and reduces adjustment reconciliation; prevents $259.74 underpayment errors
Appeal initial denials for medical necessity with detailed operative notes, pre-operative imaging, and photos demonstrating extent of deformity or injury
Impact: Increases approval rate from approximately 40% to 75-85% on appeal, recovering $1180.32 per successful overturn
For tumor-related reconstruction, ensure oncologic diagnosis codes are sequenced first and link clearly to reconstruction necessity
Impact: Reduces medical necessity denials by 60-70% and supports higher reimbursement for complex oncologic cases
Bill co-surgery (modifier 62) appropriately when multiple specialties are genuinely required; document distinct roles of each surgeon
Impact: Maximizes appropriate reimbursement for both providers while avoiding fraud risk; each surgeon receives $737.70 when properly documented

Live Field Datano reports yet

Real billers contribute denial patterns and appeal strategies for this code. Once 5+ reports come in, you’ll see live aggregated data here — the only place this exists, free.

Working with CPT 21245?

Get the free Revenue Protection Toolkit — the denial triggers, modifier pitfalls, and bundling conflicts that quietly cost you reimbursement. Instant download.

Help build the field knowledge

MedPayIQ gets smarter as billers contribute. If you've had this code denied, share what happened so others learn from it. Anonymous, no patient info.

Related actions

Frequently asked questions

What is the Medicare reimbursement rate for CPT 21245 in 2025?

The 2025 Medicare national average non-facility rate for CPT 21245 is $1180.32, while the facility rate is $920.58. Actual reimbursement may vary based on geographic location and MAC-specific adjustments.

How many RVUs is CPT code 21245 worth?

CPT 21245 has a total RVU value of 36.49, comprised of 13.12 work RVUs, 22.02 non-facility practice expense RVUs (13.99 facility PE RVUs), and 1.35 malpractice RVUs based on the 2025 Medicare Physician Fee Schedule.

What is the difference between CPT 21245 and 21244?

CPT 21244 describes reconstruction of the mandible or maxilla using endosteal implants, while 21245 covers general jaw reconstruction without the specific implant component. Code selection depends on the specific technique and materials used during reconstruction.

Does CPT 21245 require prior authorization from Medicare?

Medicare typically does not require prior authorization for 21245, but medical necessity must be clearly documented. However, Medicare Advantage plans and commercial payers often require pre-authorization for this high-cost reconstructive procedure, particularly for non-trauma cases.

Can CPT 21245 be billed bilaterally with modifier 50?

Yes, when jaw reconstruction is performed on both sides during the same operative session, modifier 50 is appropriate. This typically results in 150% reimbursement of the single-side rate, approximately $1770.48 for non-facility settings.

What diagnosis codes support medical necessity for CPT 21245?

Common supporting diagnoses include traumatic jaw fractures (S02.6xx series), malignant neoplasms requiring resection (C41.0, C41.1), congenital deformities (Q67.4, Q75.4), osteomyelitis of jaw (M86.xx), and pathologic fractures. The diagnosis must demonstrate functional impairment requiring reconstruction.

How long is the global period for CPT 21245?

CPT 21245 carries a 90-day global surgical package, meaning routine postoperative care for 90 days following surgery is included in the reimbursement and should not be billed separately unless complications arise requiring return to the operating room (modifier 78 or 79).