How To Use CPT Code 21046

CPT code 21046 describes the excision of a benign tumor or cyst of the mandible that requires intra-oral osteotomy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21046?

CPT 21046 is used to describe the surgical procedure of removing a cyst or benign tumor of the mandible, or lower jaw bone, that requires intra-oral osteotomy. The provider may use either an intraoral approach, through the mouth, or an extraoral approach, through the skin, depending on the location and nature of the tumor. This code specifically applies to cases where the tumor is locally aggressive or destructive.

2. Official Description

The official description of CPT code 21046 is: ‘Excision of benign tumor or cyst of mandible requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s]).’

3. Procedure

The excision procedure for CPT 21046 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision in the layer of mucosa covering the palate, at the roof of the mouth, for an intraoral approach. Alternatively, for an extraoral approach, the provider makes an incision in the neck or cheek, depending on the tumor’s location.
3. The provider extends the incision through fascia and muscle, down to the bone.
4. The abnormal mass is localized and marked, along with proper margins, to aid in dissection.
5. The provider uses a bone drill or osteotome to cut and remove the mass in the bone, along with the appropriate surrounding margins.
6. If the tumor is locally aggressive or destructive, the provider may need to excise additional surrounding bone tissue using a bone drill and curettes.
7. In some cases, the provider may perform bone grafting or an intraoral flap reconstruction procedure to fill in defects resulting from the extensive dissection.
8. The surgical specimen is submitted for laboratory analysis.
9. The provider checks for bleeding, removes any instruments, and closes the incision by suturing in a layered fashion.

4. Qualifying circumstances

CPT 21046 is applicable when the excision of a benign tumor or cyst of the mandible requires intra-oral osteotomy. This code is specifically used for tumors that are locally aggressive or destructive. It is important to note that the procedure must be performed by a qualified healthcare professional and meet the specific criteria outlined in the code description.

5. When to use CPT code 21046

CPT code 21046 should be used when a provider performs the excision of a benign tumor or cyst of the mandible that requires intra-oral osteotomy. This code is specifically for cases where the tumor is locally aggressive or destructive. It is important to review the documentation and ensure that all the criteria for this code are met before reporting it.

6. Documentation requirements

To support a claim for CPT 21046, the provider must document the following information:

• Patient’s diagnosis and the need for excision of the benign tumor or cyst
• Details of the surgical approach (intraoral or extraoral)
• Date of the procedure
• Specific location and characteristics of the tumor or cyst
• Extent of the excision, including any additional bone tissue removal
• Use of bone grafts or intraoral flap reconstruction, if applicable
• Details of any complications or unexpected findings
• Pathology report for the excised specimen
• Any post-operative care instructions or follow-up plans

7. Billing guidelines

When billing for CPT 21046, it is important to ensure that the excision procedure meets the specific criteria outlined in the code description. The provider should use the appropriate diagnosis code to support medical necessity. It is also important to follow any specific billing guidelines provided by the payer or relevant coding guidelines. Additionally, it is crucial to review any bundling or unbundling rules that may apply to this code.

8. Historical information

CPT code 21046 was added to the Current Procedural Terminology system on January 1, 2003. The code description was updated on January 1, 2013 to include the mention of locally aggressive or destructive lesions.

9. Similar codes to CPT 21046

There are several similar codes to CPT 21046 that may be used in different scenarios. These include:

• CPT 21045: Excision of benign tumor or cyst of mandible requiring extra-oral osteotomy (eg, ameloblastoma, fibro-osseous lesion), including contouring of bone
• CPT 21047: Excision of benign tumor or cyst of mandible requiring intra-oral osteotomy (eg, ameloblastoma, fibro-osseous lesion), including contouring of bone
• CPT 21048: Excision of benign tumor or cyst of mandible requiring extra-oral osteotomy (eg, ameloblastoma, fibro-osseous lesion), including contouring of bone; with iliac or other autogenous bone graft
• CPT 21049: Excision of benign tumor or cyst of mandible requiring intra-oral osteotomy (eg, ameloblastoma, fibro-osseous lesion), including contouring of bone; with iliac or other autogenous bone graft
• CPT 21050: Excision of benign tumor or cyst of mandible requiring extra-oral osteotomy (eg, ameloblastoma, fibro-osseous lesion), including contouring of bone; with microvascular bone transfer (includes obtaining graft and microvascular anastomosis)

9. Examples

1. A patient undergoes excision of a locally aggressive ameloblastoma of the mandible using intra-oral osteotomy.
2. A provider performs the removal of a destructive fibro-osseous lesion of the mandible through an extra-oral approach.
3. An intra-oral osteotomy is performed to excise a locally aggressive cyst of the mandible.