Oral Surgery Coding & Reimbursement Alert

Question: Our oral surgeon recently performed a maxillary sinus lift procedure using bone grafts. How will I report this procedure that was performed using CPT® codes as we are submitting the claims to a medical insurance carrier?

Indiana Subscriber

Answer: When your clinician performs a sinus lift procedure, you will have to report it with the CPT® code 21210 (Graft, bone; nasal, maxillary or malar areas [includes obtaining graft]). If you look at the descriptor to 21210, you’ll notice that the code includes the work that your surgeon performed in obtaining the graft material from another site. So, you should not report the surgical aspect of obtaining the graft material separately using another CPT® code.

Sometimes, your clinician might look at other options for the graft material instead of obtaining it from another site from the same patient. So, for example, if he uses any bone graft substitute instead of bone grafts from the patient or from any other donor, you’ll still continue to report it with the same CPT® code, 21210. Since there is no work involved in obtaining the graft material as is the case when your surgeon obtains the graft material from the patient, you will have to append the modifier 52 (Reduced services) to 21210.

Since you have not described what bone graft your clinician used, depending on the scenario, you’ll have to report 21210 if your clinician is using bone grafts from the same patient or from any other donor or use 21210-52 if your surgeon is using a synthetic bone graft substitute.