CPT 21247Surgery

Reconstruct lower jaw bone

CPT code 21247 covers surgical reconstruction of the lower jaw bone (mandible), typically performed after trauma, tumor removal, or congenital defects. This complex procedure involves reshaping or rebuilding the jawbone structure to restore function and appearance.

Showing rates for

National Average

Base Medicare rate

$1,535.81

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

24.37

PE RVU (NF)

20.65

MP RVU

2.46

Total RVU

47.48

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

NCCI bundling edits

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Billing tips

Document precise anatomical location and extent of reconstruction including specific mandibular segments involved (symphysis, body, ramus, angle)
Impact: Prevents downcoding and supports medical necessity; lack of anatomical detail causes 15-20% of initial denials for 21247
Clearly differentiate 21247 from codes requiring bone graft (21194, 21215) or osteotomy (21198) in operative notes
Impact: Prevents unbundling denials and clarifies why higher-value codes were not appropriate; saves average $400-800 in appeal costs
Submit pre-authorization with detailed surgical plan, imaging, and medical necessity documentation for non-trauma cases
Impact: Increases first-pass approval rate by 60-70% for elective reconstructions; reduces payment delays by 30-45 days
Code fixation hardware (plates, screws) separately only if specifically documented as requiring additional surgical effort beyond typical 21247
Impact: Hardware is typically bundled; inappropriate separate billing triggers audits and potential $500-1000 recoupment per case
Document total operative time, surgical approach, and any unusual procedural complexity to support modifier 22 when applicable
Impact: Well-documented modifier 22 can increase reimbursement by $307-460 (20-30% above base rate) for complex cases
Verify global period (90 days) and avoid billing separately for routine postoperative visits or minor complications
Impact: Prevents automatic denials and potential fraud investigations; each inappropriate E/M during global period triggers $50-150 recoupment

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 21247 in 2025?

The 2025 Medicare national average reimbursement for CPT 21247 is $1535.81 for both facility and non-facility settings. This rate is based on 47.48 total RVUs multiplied by the 2025 conversion factor of $32.3465. Actual reimbursement may vary by geographic locality adjustment.

What is the difference between CPT 21247 and 21194 for jaw reconstruction?

CPT 21247 covers mandibular reconstruction without bone graft or prosthetic material, typically involving repositioning and fixation of existing bone. CPT 21194 describes reconstruction using bone graft, which involves harvesting or obtaining graft material and incorporating it into the mandible. The presence or absence of graft material is the key distinguishing factor.

How many RVUs is CPT code 21247 worth?

CPT 21247 has 47.48 total RVUs for 2025, comprised of 24.37 work RVUs, 20.65 practice expense RVUs, and 2.46 malpractice RVUs. Both facility and non-facility PE RVUs are identical at 20.65 for this surgical code.

Does CPT 21247 require pre-authorization from insurance?

Most commercial payers and Medicare Advantage plans require pre-authorization for CPT 21247 due to its surgical nature and high reimbursement value. Traditional Medicare typically does not require pre-authorization but may conduct medical necessity review. Always verify specific payer requirements before scheduling surgery to avoid denials.

Can CPT 21247 be billed bilaterally with modifier 50?

Yes, modifier 50 can be appended to CPT 21247 when bilateral mandibular reconstruction is performed during the same operative session. This typically increases reimbursement to 150% of the unilateral rate ($2303.72 for Medicare), but requires clear documentation of bilateral necessity and distinct work on each side.

What is the global period for CPT code 21247?

CPT 21247 has a 90-day global surgical period. This means routine postoperative care for 90 days following surgery is included in the reimbursement and cannot be billed separately. Only complications requiring return to the operating room (with modifier 78) or unrelated E/M services (with modifier 24) can be billed during this period.

What diagnosis codes are typically used with CPT 21247?

Common ICD-10 codes paired with CPT 21247 include S02.609A (mandibular fracture), M26.09 (other dentofacial anomalies), D16.5 (benign neoplasm of mandible), C41.1 (malignant neoplasm of mandible), and M84.164A (pathological fracture). The diagnosis must demonstrate medical necessity for reconstruction and support functional rather than purely cosmetic intent.