Surgical · Other

Impression and custom fabrication of an external nasal prosthesis for a patient with partial or total nasal absence due to ablative surgery, trauma, or congenital defect.

Verified May 8, 2026 · 7 sources ↓

Medicare: $1,627.29
Total RVUs: 48.72
Global, days: 90
Region: Other

Drawn from CMSFastrvuAAPCCgsmedicare

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 7 cited references ↓

Clinical indication documenting nasal absence or defect — specify etiology (post-surgical, traumatic, or congenital) with supporting operative or pathology records
Description of the impression technique used and materials selected for prosthesis fabrication
Fitting and adjustment notes confirming the prosthesis was delivered and fit to the patient
Diagnosis code that precisely matches the documented etiology — acquired absence vs. congenital anomaly requires different ICD-10 coding
If performed during or following an oncologic resection, link pathology report confirming the need for nasal reconstruction
Identification of all providers involved — note any assistant surgeon role if modifier 80 is appended

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 52 Reduced services 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

CPT 21087 covers the full workflow of creating a custom nasal prosthesis: taking a negative impression of the nasal region, fabricating the device to fit the individual's anatomy, and delivering the finished prosthesis. The procedure is performed most often by oral and maxillofacial surgeons following rhinectomy for malignancy, significant nasal trauma with tissue loss, or congenital absence. The 90-day global period means any prosthesis adjustments or fittings related to the original device are bundled — bill modifier 78 only if an unplanned return to a procedure room is required for a related issue within the global window.

The dramatic gap between the HOPD and ASC facility payment rates for this code reflects site-of-service payment policy. Surgeons billing in the office setting should confirm their practice has the appropriate setup for impression-taking and prosthetic fabrication, and that documentation captures the clinical indication, materials used, and fitting adjustments — not just a procedure label. Maxillofacial prosthodontists and anaplastologists frequently collaborate on these cases; if an assistant is involved, modifier 80 applies.

ICD-10 diagnosis coding must align precisely: nasal absence following surgery (typically Z90.09 or a site-specific acquired absence code) or a congenital nasal anomaly code depending on etiology. Payers will scrutinize medical necessity documentation, particularly for trauma cases, so operative or pathology reports from the underlying procedure that created the defect should be linked in the record.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	24.26
Practice expense RVU	21.7
Malpractice RVU	2.76
Total RVU	48.72
Medicare national rate	$1,627.29
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$1,627.29
HOPD (APC 5165) Hospital outpatient department	$6,048.05
ASC (PI P3) Ambulatory surgical center (freestanding)	$728.41

Common denial reasons

The recurring reasons claims for CPT 21087 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Medical necessity not established — missing prior operative or pathology report documenting why nasal tissue is absent
Diagnosis code mismatch — billing an acquired absence code when records reflect a congenital condition, or vice versa
Duplicate or global period conflict — payer bundles a fitting visit billed separately within the 90-day global as an inclusive service
Site-of-service mismatch — procedure billed under a facility that lacks documented prosthetic fabrication capability
Missing or vague operative note that does not describe impression technique, materials, or final fitting of the prosthesis

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01What is the global period for CPT 21087, and what does it include?

21087 carries a 90-day global period. Routine prosthesis checks, minor adjustments, and follow-up fittings within that window are bundled. Unplanned returns to a procedure room for a related complication require modifier 78; unrelated procedures require modifier 79.

02Which diagnosis codes support medical necessity for 21087?

The diagnosis must reflect nasal absence or defect. Acquired absence following surgery maps to codes in the Z90 category; traumatic loss uses the appropriate injury sequela code; congenital anomalies use Q codes. Using a generic facial disorder code without documenting the specific defect invites denial.

03Can 21087 be billed with other facial prosthetic or reconstructive codes on the same date?

If multiple distinct prosthetic services are performed at separate anatomic sites, modifier 59 or XS may allow separate billing, but confirm NCCI PTP edits for the specific code pair using the CMS NCCI lookup tool before billing both codes. Incidental services are not separately reportable.

04Why is the HOPD payment so much higher than the ASC payment for this code?

The site-of-service differential is a CMS policy feature — HOPD payments incorporate higher facility overhead. The physician's professional fee is the same regardless of setting; the facility component is what drives the gap. See the Site of Service comparison on this page.

05Does modifier 22 apply when fabricating a prosthesis for a complex or severely disfigured nasal defect?

Yes — if the defect anatomy required substantially more work than a standard impression and fabrication (e.g., extensive scarring, unusual contouring, multiple remakes), append modifier 22 and include a cover letter with the claim documenting the specific additional work and time involved. Expect the payer to request medical records.

06Who typically performs and bills CPT 21087?

CMS PUF data shows Oral Surgery (Dentist only) as the dominant billing specialty. Maxillofacial surgeons and anaplastologists also perform this service. If a non-physician anesthesia provider assists, use modifier AS; for a physician assistant surgeon, use modifier 80.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the clinical indication (post-rhinectomy, traumatic loss, or congenital absence), impression technique, materials used in fabrication, and fitting outcome from dictation — generating structured documentation that links directly to the supporting diagnosis code. That prevents the most common denial: a procedure note that describes the prosthesis delivery without establishing why the nasal tissue is absent in the first place.

See how Mira captures CPT 21087 documentation