How To Use CPT Code 21048

CPT code 21048 describes the excision of a benign tumor or cyst of the maxilla that requires an 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 21048?

CPT 21048 is used to describe the surgical excision of a benign tumor or cyst of the maxilla that requires an intra-oral osteotomy. This code is used when the provider performs an open surgical procedure to remove a fast-growing or destructive tumor from the upper jaw bone.

2. Official Description

The official description of CPT code 21048 is: ‘Excision of benign tumor or cyst of maxilla requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s]).’

3. Procedure

The procedure for CPT code 21048 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision through the oral mucosa, the membrane layer inside the mouth, to access the deep-rooted cyst or complex benign tumor of the maxillary bone.
3. The provider localizes the mass and marks it along with the proper margins as a guide during dissection.
4. A bone drill or osteotome is used to cut out and remove the mass, along with appropriate surrounding margins.
5. The provider prevents further extension of the benign tumor or cyst by drilling, curetting, and excising surrounding bone and tissues.
6. Bone grafts may be applied or an intraoral flap may be utilized to fill in defects in the bone and tissues.
7. A tissue specimen is submitted for laboratory analysis.
8. The provider checks for bleeding, removes any instruments, and closes the incision by suturing in a layered fashion.

4. Qualifying circumstances

CPT 21048 is used for the excision of a benign tumor or cyst of the maxilla that requires an intra-oral osteotomy. This code is appropriate when the tumor or cyst is locally aggressive or destructive. It is important to note that the tumor or cyst must be benign, not cancerous.

5. When to use CPT code 21048

CPT code 21048 should be used when a provider performs an excision of a benign tumor or cyst of the maxilla that requires an intra-oral osteotomy. This code is specific to cases where the tumor or cyst is locally aggressive or destructive. It should not be used for excisions of tumors or cysts in other locations or for different types of lesions.

6. Documentation requirements

To support a claim for CPT 21048, the provider must document the following information:

• Patient’s diagnosis indicating the presence of a benign tumor or cyst of the maxilla
• Description of the tumor or cyst, including its size and characteristics
• Details of the intra-oral osteotomy performed
• Documentation of any bone grafts or intraoral flaps used
• Tissue specimen submission for laboratory analysis
• Details of the closure technique used

7. Billing guidelines

When billing for CPT 21048, ensure that the excision of the benign tumor or cyst of the maxilla requires an intra-oral osteotomy. This code should not be reported with other codes unless additional procedures or services were performed during the same operative session. It is important to follow the specific guidelines provided by the payer and to accurately document the procedure performed.

8. Historical information

CPT 21048 was added to the Current Procedural Terminology system on January 1, 2003. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 21048

There are several similar codes to CPT 21048 that describe excision procedures on the head. Some examples include:

• CPT 21011: Excision of benign tumor or cyst of mandible or maxilla
• CPT 21012: Excision of benign tumor or cyst of mandible or maxilla with autograft
• CPT 21013: Excision of benign tumor or cyst of mandible or maxilla with allograft
• CPT 21014: Excision of benign tumor or cyst of mandible or maxilla with prosthetic implant
• CPT 21015: Excision of benign tumor or cyst of mandible or maxilla with bone graft

9. Examples

1. A patient undergoes an excision of a locally aggressive benign tumor of the maxilla that requires an intra-oral osteotomy.
2. A provider performs the excision of a destructive cyst of the maxilla using an intra-oral osteotomy.
3. An individual undergoes the removal of a fast-growing benign tumor of the maxilla that requires an intra-oral osteotomy.
4. A patient undergoes the excision of a complex benign tumor of the maxilla that is locally aggressive and requires an intra-oral osteotomy.
5. A provider performs the removal of a destructive cyst of the maxilla using an intra-oral osteotomy technique.
6. An individual undergoes the excision of a fast-growing benign tumor of the maxilla that requires an intra-oral osteotomy.
7. A patient undergoes the removal of a locally aggressive benign tumor of the maxilla using an intra-oral osteotomy.
8. A provider performs the excision of a complex benign tumor of the maxilla that is locally aggressive and requires an intra-oral osteotomy.
9. An individual undergoes the removal of a destructive cyst of the maxilla using an intra-oral osteotomy technique.
10. A patient undergoes the excision of a fast-growing benign tumor of the maxilla that requires an intra-oral osteotomy.