How To Use CPT Code 21049

CPT code 21049 describes the excision of a benign tumor or cyst of the maxilla that requires an extra-oral osteotomy and partial maxillectomy. 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 21049?

CPT 21049 is used to describe the surgical procedure of removing a benign tumor or cyst of the maxilla that requires an extra-oral osteotomy and partial maxillectomy. 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 21049 is: ‘Excision of benign tumor or cyst of maxilla requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion[s]).’

3. Procedure

During the procedure for CPT 21049, the patient is appropriately prepped and anesthetized. The provider makes a curvilinear incision in the skin of the neck or cheek region, depending on the location of the tumor. They incise through the fascia and muscle along the tragus line, which is an anatomical landmark in front of the ear, to access the deep-rooted cyst or complex benign tumor of the maxillary bone.

The provider localizes the mass and marks it along with the proper margins as an aid in dissection. They use a bone drill or osteotome to remove the portion of the maxillary bone containing the mass. To prevent further extension of the complex benign tumor or deep-rooted cyst, they drill, curette, and excise surrounding bone and tissues. Bone grafts may be applied to fill in bony defects.

The provider then submits a tissue specimen for laboratory analysis and checks for bleeding. They remove any instruments and finally close the incision by suturing in a layered fashion.

4. Qualifying circumstances

CPT 21049 is performed on patients with a benign tumor or cyst of the maxilla that requires surgical excision. These tumors or cysts may be locally aggressive or destructive. The procedure involves an extra-oral osteotomy and partial maxillectomy, indicating the need for removal of a portion of the maxillary bone.

5. When to use CPT code 21049

CPT code 21049 should be used when a provider performs an excision of a benign tumor or cyst of the maxilla that requires an extra-oral osteotomy and partial maxillectomy. This code is specific to cases where the tumor or cyst is locally aggressive or destructive.

6. Documentation requirements

To support a claim for CPT 21049, the provider must document the following information:

• Patient’s diagnosis and the need for surgical excision
• Details of the procedure, including the extra-oral osteotomy and partial maxillectomy
• Location and size of the tumor or cyst
• Use of bone grafts, if applicable
• Tissue specimen submission for laboratory analysis
• Details of closure, including suturing technique

7. Billing guidelines

When billing for CPT 21049, ensure that the procedure meets the requirements of an excision of a benign tumor or cyst of the maxilla requiring an extra-oral osteotomy and partial maxillectomy. There are no specific guidelines regarding reporting CPT 21049 with other codes.

8. Historical information

CPT 21049 was added to the Current Procedural Terminology system on January 1, 2003. There have been no updates to the code since its addition.

9. Similar codes to CPT 21049

There are no similar codes to CPT 21049 within the range of excision procedures on the head (21011-21070).

9. Examples

1. A provider performs an excision of a locally aggressive benign tumor of the maxilla requiring an extra-oral osteotomy and partial maxillectomy.
2. A patient undergoes a surgical procedure to remove a destructive cyst of the maxilla that requires an extra-oral osteotomy and partial maxillectomy.
3. A provider excises a fast-growing tumor of the maxilla that is causing significant destruction, requiring an extra-oral osteotomy and partial maxillectomy.
4. A patient undergoes surgery to remove a complex benign tumor of the maxilla that is locally aggressive, necessitating an extra-oral osteotomy and partial maxillectomy.
5. A provider performs an excision of a deep-rooted cyst of the maxilla that is causing destruction, requiring an extra-oral osteotomy and partial maxillectomy.
6. A patient undergoes surgery to remove a locally aggressive benign tumor of the maxilla that requires an extra-oral osteotomy and partial maxillectomy.
7. A provider excises a destructive cyst of the maxilla that is growing rapidly, necessitating an extra-oral osteotomy and partial maxillectomy.
8. A patient undergoes surgery to remove a complex benign tumor of the maxilla that is causing significant destruction, requiring an extra-oral osteotomy and partial maxillectomy.
9. A provider performs an excision of a deep-rooted cyst of the maxilla that is locally aggressive, necessitating an extra-oral osteotomy and partial maxillectomy.
10. A patient undergoes surgery to remove a locally aggressive benign tumor of the maxilla that requires an extra-oral osteotomy and partial maxillectomy.