2025 CPT code 21048
Effective Date: N/A Surgery - Musculoskeletal System Feed
Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (e.g., locally aggressive or destructive lesion(s)).
Medical necessity is established by documentation demonstrating the presence of a benign tumor or cyst of the maxilla causing pain, dysfunction, or other significant symptoms, along with its aggressive or destructive nature requiring an intraoral approach.
The surgeon prepares the patient and administers anesthesia. An incision is made through the oral mucosa to access the tumor or cyst. The surgeon then uses surgical instruments to remove the growth, often with some surrounding bone tissue, and may utilize bone grafts or flaps to reconstruct the area. The removed tissue is sent for laboratory analysis. The incision is closed with sutures.
In simple words: This procedure involves removing a non-cancerous growth or cyst from the upper jawbone through the mouth. The surgeon makes a cut in the bone to access and remove the growth, and may use a bone graft or flap to repair any resulting defects.
This code describes the surgical removal of a non-cancerous tumor or cyst located in the maxilla (upper jaw bone) that requires an intraoral osteotomy. This procedure is typically employed when the lesion is locally aggressive, destructive, or deeply rooted, necessitating access through the oral cavity and cutting into the maxillary bone.
Example 1: A patient presents with a large, locally aggressive ameloblastoma (a benign but destructive tumor) in the maxilla. The surgeon performs an intraoral osteotomy to remove the tumor., A patient has a large keratocystic odontogenic tumor in the posterior maxilla that is causing significant bone destruction. An intraoral osteotomy is required to access and completely remove the tumor., A patient has a complex odontogenic cyst deeply embedded within the maxilla. An intraoral osteotomy is performed to remove the cyst and prevent recurrence.
Documentation should include details of the lesion (size, location, characteristics), pre-operative imaging, operative report detailing the procedure (including osteotomy, excision, and any reconstruction performed), and post-operative diagnosis from pathology.
- Specialties:Oral and Maxillofacial Surgery, Otolaryngology (Head and Neck Surgery)
- Place of Service:Ambulatory Surgical Center, Hospital - Outpatient, Inpatient Hospital