2025 CPT code 21210

Bone graft to nasal, maxillary, or malar areas; includes obtaining the graft.

Report 21210 only once per sinus floor bone augmentation or sinus lift. If two providers are involved (one harvesting and one placing the graft), each should report 21210 with modifier 62.If using only freeze-dried bone and not harvesting autologous bone, append modifier 52.For multiple grafts on the maxilla at separate sites, append modifier 59 to the additional 21210 code.Modifier 50 is not typically accepted by Medicare for bilateral maxillary grafts.

Modifiers 52, 59, and 62 may be applicable depending on the specific circumstances of the procedure.

Medical necessity for bone grafting is established by the presence of a significant bony defect, deformity, or fracture requiring reconstruction to restore form and function.The procedure must be deemed medically necessary by the treating physician and justified based on the patient's clinical presentation and diagnostic findings.

The surgeon is responsible for all aspects of the procedure, including patient preparation, anesthesia, bone graft harvesting (or acquisition of donor bone), graft placement and fixation, and wound closure.

IMPORTANT For cleft palate repair, see codes 42200-42225.For cranioplasty, see codes 21179, 21180, 62120, and 62140-62147.

In simple words: The doctor uses a bone graft (either from the patient's own body or a donor) to repair broken or damaged bones in the nose, upper jaw, or cheek area. This includes taking the bone graft and putting it in place.

This CPT code encompasses the surgical procedure of applying bone graft material to the nasal, maxillary, or malar (cheekbone) areas of the face to correct cosmetic deformities resulting from injury or disease.The procedure includes obtaining the bone graft, which may involve harvesting autograft material (from the patient's own body, often the hip bone) or using donor bone. The graft is positioned at the defect site, either superficially or deep to the nasal bone, and secured with screws, plates, or wires. Wound closure is achieved with layered sutures.

Example 1: A patient presents with a malar fracture resulting from a motor vehicle accident. The surgeon performs a bone graft using autologous iliac crest bone to reconstruct the fractured zygomatic arch., A patient undergoes a rhinoplasty and requires a bone graft to augment the nasal dorsum due to prior trauma. The surgeon harvests autologous rib cartilage and places it using internal fixation. , A patient with a congenital maxillary deficiency undergoes a Le Fort I osteotomy with bone grafting for facial reconstruction. Allogeneic bone is used to supplement the autologous bone graft.

* Preoperative diagnosis and imaging studies (e.g., CT scan, radiographs) demonstrating the need for bone grafting.* Operative report detailing the technique of bone graft harvesting (or source of donor bone), graft placement, fixation method, and amount of bone graft used.* Postoperative imaging studies (if applicable) to assess graft integration and healing.* Pathology report (if applicable) confirming the diagnosis of the underlying condition.

** The cost of freeze-dried bone or other graft materials is included in the code.Appreciable vessel exploration or neuroplasty should be reported separately.

  • Revenue Code: P3D (MAJOR PROCEDURE, ORTHOPEDIC - OTHER)
  • Payment Status: Active
  • Specialties:Plastic Surgery, Oral and Maxillofacial Surgery, ENT (Otolaryngology)
  • Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Office
** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.