Soft tissue repair · Other

21248

Partial reconstruction of the mandible or maxilla using an endosteal implant (such as a blade or cylinder type) placed directly into the jawbone.

Verified May 8, 2026 · 6 sources ↓

Medicare
$1,023.40
Total RVUs
30.64
Global, days
90
Region
Other
Drawn from AaomsAAPCFindacodeCMS

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

  • Specify whether reconstruction is mandible or maxilla and which arch segments are involved to support partial (21248) vs. complete (21249) selection.
  • Document the implant type by name (e.g., blade, cylinder, endosteal plate) and material (metallic or ceramic).
  • Include pre-operative imaging (panoramic radiograph, CT scan) showing the bone defect, atrophy, or pathology necessitating reconstruction.
  • State the medical necessity indication explicitly — trauma sequelae, tumor resection, congenital defect, or severe functional bone loss — not cosmetic restoration.
  • Record tooth count or arch percentage reconstructed to justify partial vs. complete code selection.
  • Document approach, implant placement technique, bone graft use (if any), and any concomitant procedures performed during the same operative session.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 52 Reduced services 59 Distinct service 62 Co-surgeons 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 21248 covers partial reconstruction of the mandible or maxilla using an endosteal implant — a blade, cylinder, or similar device embedded directly into the jawbone. 'Partial' is defined by arch extent, not implant count: use 21248 when the reconstruction replaces three or fewer teeth or involves less than one-half of the dental arch. When four or more teeth are replaced or more than half the arch is reconstructed, step up to 21249.

This code sits in the CPT musculoskeletal surgery section under Repair, Revision, and/or Reconstruction Procedures on the Head. It carries a 90-day global period, meaning preoperative visits, the operative day, and all routine post-op care through day 90 are bundled. Anything outside that package — a new problem, a staged revision, an unrelated procedure — requires modifiers 24, 79, or 58, respectively. The procedure is almost exclusively billed by oral and maxillofacial surgeons; Medicare's top billing specialties are Oral Surgery (Dentist only) and Dentist.

Prior authorization is routine for this code given the facility payment differential between HOPD and ASC settings (see site-of-service comparison). Diagnosis coding must clearly establish medical necessity — tumor resection sequelae, trauma, congenital defect, or severe bone loss — rather than routine dental rehabilitation. Carriers increasingly scrutinize 21248 claims lacking imaging-supported bone defect documentation and a functional, not cosmetic, indication.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU12.42
Practice expense RVU16.71
Malpractice RVU1.51
Total RVU30.64
Medicare national rate$1,023.40
Global period90 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

SettingMedicare rate (national)
Office (PFS non-facility)
Procedure performed in physician's office
$1,023.40
HOPD (APC 5165)
Hospital outpatient department
$6,048.05
ASC (PI A2)
Ambulatory surgical center (freestanding)
$3,025.62

Common denial reasons

The recurring reasons claims for CPT 21248 get rejected.

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

  • Wrong code level — billing 21248 when arch extent meets 21249 criteria (four or more teeth or more than half the arch reconstructed).
  • Missing or insufficient medical necessity documentation; carriers deny when indication reads as cosmetic or dental rehabilitation rather than functional reconstruction.
  • Absence of pre-operative imaging in the record to corroborate the bone defect requiring implant reconstruction.
  • Global period conflict — post-op visits billed without modifier 24 when they fall within the 90-day global and are flagged as routine care.
  • Prior authorization not obtained before procedure for procedures performed in HOPD or ASC settings.
  • Diagnosis code mismatch — using a routine dental loss code (K08 series) without specificity to support the functional reconstruction indication.

Frequently asked questions

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

01What is the difference between CPT 21248 and 21249?
The split is based on arch extent, not implant count. Use 21248 when three or fewer teeth are replaced or less than half the dental arch is reconstructed. Use 21249 when four or more teeth are replaced or more than half the arch is involved. Placing multiple implants in a limited segment does not automatically upgrade the code to 21249.
02Does CPT 21248 require prior authorization?
Most commercial payers and Medicare Advantage plans require prior authorization for 21248 given its high facility payment. Submit imaging and a written functional necessity statement — not just a diagnosis code — with the PA request. Approval rates vary significantly when the indication is ambiguous between functional reconstruction and elective dental restoration.
03How is the 90-day global period managed for 21248?
The 90-day global bundles the day-before pre-op visit, the surgery date, and all routine post-op care through day 90. Modifier 24 is required to bill an E/M for an unrelated problem during the global. Modifier 78 covers an unplanned return to the OR for a related complication. Modifier 79 applies to an unrelated surgical procedure performed during the global period.
04Can modifier 62 be used for CPT 21248?
Yes. When a maxillofacial surgeon and another surgeon — for example, a reconstructive plastic surgeon or a neurosurgeon managing adjacent structures — each perform distinct portions of the procedure as co-primary surgeons, both bill 21248 with modifier 62. Both operative reports must document each surgeon's distinct role and the medical necessity for two primaries.
05Which ICD-10 diagnosis codes best support medical necessity for 21248?
The AAOMS coding guidance points to categories M27 (other diseases of jaws), K08 (disorders of teeth and supporting structures), and trauma or neoplasm sequelae codes. The key is selecting a code that reflects a structural or functional defect — bone loss, resection defect, congenital anomaly — not routine edentulism. Payers are more likely to approve when imaging findings are paired with a specific defect code.
06Is 21248 ever billed in an office setting?
It can be reported with place of service 11 (office) for a procedure performed in a properly equipped oral surgery suite, but the site-of-service payment differential is significant. Most insurers and Medicare expect facility-level settings (HOPD or ASC) for this procedure. Billing office-based when the procedure occurred in a facility will trigger a payment adjustment or denial.

Sources & references

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

  1. 01
    aaoms.org
    https://aaoms.org/wp-content/uploads/2024/04/OralImplants_CodingPaper.pdf
  2. 02
    aapc.com
    https://www.aapc.com/codes/cpt-codes/21248
  3. 03
    findacode.com
    https://www.findacode.com/cpt/21248-cpt-code.html
  4. 04
    cms.gov
    https://www.cms.gov/files/document/2025nccimedicarepolicymanualcompletepdf.pdf
  5. 05
    cms.gov
    https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-medically-unlikely-edits-mues
  6. 06CMS Physician Fee Schedule 2026

Mira AI Scribe

Mira's AI scribe captures the implant type and material, the specific jaw segment reconstructed, the tooth count or arch percentage involved, and the clinical indication from dictation — locking in the partial vs. complete distinction that separates 21248 from 21249. It also flags whether concomitant grafting or a second surgeon was involved, preventing the most common down-code and co-surgeon modifier omission denials.

See how Mira captures CPT 21248 documentation

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