CPT® Code 21048

Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s])

The procedure described by CPT® Code 21048 involves the excision of a benign tumor or cyst located in the maxilla, which is the upper jawbone. This procedure is specifically indicated when the tumor or cyst is locally aggressive or destructive, necessitating an intra-oral osteotomy. In simpler terms, the physician will access the tumor through the mouth, making an incision in the muscle tissue to create a flap that can be reflected to expose the underlying structures. Once the tumor is located, it is carefully excised along with a portion of the surrounding bone to ensure complete removal and to minimize the risk of recurrence. In cases where an extraoral approach is required, the physician will make an incision outside the mouth, continuing to dissect through the tissue layers until the tumor is accessible for removal. This approach may also involve the excision of part of the maxilla itself. After the tumor is removed, the surgical site may be packed to control bleeding, and in some instances, a bone graft may be necessary to support the structural integrity of the maxilla. Finally, the incisions made during the procedure are sutured in layers to promote proper healing and minimize scarring.