Surgical · Other

Reconstruction of the mandibular condyle using bone and cartilage harvested from the patient's own body, including autograft harvest, typically performed for congenital jaw deformity such as hemifacial microsomia.

Verified May 8, 2026 · 6 sources ↓

Medicare: $1,419.20
Total RVUs: 42.49
Global, days: 90
Region: Other

Drawn from CMSUhcproviderFastrvuAAPC

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Diagnosis documenting condylar absence, deformity, or destruction — specify congenital vs. acquired etiology
Imaging (CT preferred) confirming condylar anatomy and extent of deformity prior to surgery
Operative note specifying the donor graft site, type of material harvested (bone, cartilage, or composite), and fixation technique used at the condyle
Functional impairment documented in history: malocclusion, restricted jaw opening, asymmetry affecting mastication or speech
Prior authorization approval reference number attached to claim when required by payer
Anesthesia and hospital records confirming facility setting to support place-of-service coding

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 62 Co-surgeons 74 Discontinued post-anesthesia 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 21247 describes open surgical reconstruction of the mandibular condyle — the articulating head of the lower jaw — using autogenous bone and cartilage grafts. Both the condylar reconstruction and the harvest of donor material are captured under a single code; no separate graft-harvest code is reported. The procedure addresses structural absence or severe underdevelopment of the condyle, most commonly from congenital conditions like hemifacial microsomia, but also from ankylosis, tumor resection, or significant trauma that has destroyed condylar anatomy.

The 90-day global period means all routine postoperative care — splint adjustments, wound checks, and follow-up imaging interpretation — is bundled from day 0 through day 90. Services unrelated to the reconstruction during that window require modifier 24 (E/M) or modifier 79 (unrelated procedure). Because this is a craniofacial reconstruction, prior authorization is nearly universal across commercial payers; UnitedHealthcare's orthognathic surgery policy explicitly lists 21247 and requires documented functional impairment tied to a facial skeletal abnormality.

Site of service matters significantly here. The HOPD and ASC facility payments differ substantially — see the Site of Service comparison table. The procedure is almost always performed in a hospital or ASC setting, so the facility rate governs reimbursement to the surgeon at the non-facility work RVU level.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	23.76
Practice expense RVU	15.28
Malpractice RVU	3.45
Total RVU	42.49
Medicare national rate	$1,419.20
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	$1,419.20
HOPD (APC 5165) Hospital outpatient department	$6,048.05
ASC (PI G2) Ambulatory surgical center (freestanding)	$3,025.62

Common denial reasons

The recurring reasons claims for CPT 21247 get rejected.

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

Cosmetic vs. reconstructive determination — payer denies without documented functional impairment linked to the skeletal deformity
Missing or expired prior authorization — most commercial payers require pre-approval for all orthognathic surgery codes including 21247
Incorrect place of service code causing mismatch with billed facility fee arrangement
Operative note lacks graft harvest documentation, triggering a separate harvest code audit or downcoding
Global period violation — E/M or minor procedure billed post-op without modifier 24 or 79

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01Is the autograft harvest billed separately under 21247?

No. The code descriptor explicitly includes obtaining the autografts. Billing a separate graft-harvest code alongside 21247 will trigger an NCCI bundling edit.

02Can 21247 be billed bilaterally with modifier 50?

Bilateral condylar reconstruction in a single session is rare but not impossible in symmetric congenital conditions. If both condyles are reconstructed, modifier 50 applies and the operative note must document distinct work at each condyle. Expect payer scrutiny — attach a detailed operative report.

03What modifier applies if a second, unrelated jaw procedure is needed during the 90-day global?

Modifier 79 covers unrelated procedures performed during the global period. Modifier 78 is for unplanned returns to the OR for a complication or directly related reason — do not use them interchangeably.

04Does UnitedHealthcare cover 21247 for hemifacial microsomia?

UHC's orthognathic surgery policy lists 21247 as a covered code when there is a documented facial skeletal abnormality causing functional impairment. Prior authorization is required, and the clinical submission must link the congenital deformity to the functional deficit.

05Can modifier 22 be used if the reconstruction required significantly more work than typical?

Yes. If extensive scarring from prior surgery, severe hypoplasia, or complex graft shaping added substantial operative time and effort, modifier 22 is appropriate. The operative note must quantify the added difficulty — generic statements about complexity are regularly rejected. Attach a cover letter explaining the specific factors.

06Is 21247 appropriate when an alloplastic implant is used instead of autograft?

No. 21247 is specific to autogenous bone and cartilage grafts. Alloplastic condylar reconstruction uses different codes. Using 21247 for an implant-based reconstruction is a coding error that will not survive audit.

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 condyle-specific anatomy dictated intraoperatively — donor site location, graft composition (bone, cartilage, or osteochondral composite), fixation method, and the underlying diagnosis driving reconstruction. That detail directly answers the two questions payers ask first: is the graft autogenous (required for this code) and is the indication functional rather than cosmetic? Missing either element is the most common route to a medical necessity denial.

See how Mira captures CPT 21247 documentation