CPT code 20551: Tendon injection billing, rates, and modifiers
CPT code 20551 covers one injection into a tendon origin or insertion. Medicare ...
Last Updated: August 6, 2026
Key takeaways
CPT code 21026 covers excision of facial bone for osteomyelitis or a bone abscess. Bone grafting is billed separately.
Anatomic site is the only differentiator. Use CPT 21025 for the mandible and 21026 for the other facial bones.
CMS gives 21026 a work RVU of 5.70 and a 90-day global period. Payment then shifts with locality and setting.
CMS pays no assistant surgeon and no co-surgeon on this code. Modifier 50 brings no 150% bilateral uplift either.
Jaw osteomyelitis maps to ICD-10-CM M27.2. Reserve the M86 other-site codes for the zygoma, orbit, and nasal bones.
Practice management software like Pabau flags missing documentation before submission, so surgical teams file cleaner claims.
CPT code 21026 bills for excision of a facial bone, performed for osteomyelitis or a bone abscess. The American Medical Association descriptor reads Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s). It sits in the musculoskeletal system section of the CPT manual, inside the 21000-21499 head subsection.
Oral and maxillofacial surgeons, craniofacial surgeons, and head-and-neck specialists are its main users. CPT 21025 describes the same operation on the mandible, so anatomic site is the only thing separating the two codes. Neither descriptor includes bone grafting, which is reported separately under 21210 or 21215.
CMS also attaches three payment-policy indicators to 21026 that change which modifiers it will accept. They rule out an assistant surgeon, rule out co-surgery, and cancel the usual bilateral uplift. The modifier section below covers each one.
Clinical overview: When is CPT 21026 used?
Osteomyelitis of the facial bones is the primary clinical driver for CPT 21026. The infection turns bone tissue necrotic, and excision becomes necessary once antibiotic therapy alone stops working.
Oral and maxillofacial surgeons at craniofacial practices meet this code most often in the following scenarios:
- Maxillary osteomyelitis secondary to odontogenic infections, failed implants, or sinusitis complications
- Post-traumatic osteomyelitis of the zygoma, orbital floor, or nasal bones after fracture repair or hardware infection
- Sequestrum removal from a facial bone in chronic osteomyelitis, where necrotic fragments have separated from viable tissue
- Post-radiation osteonecrosis of the maxilla or midface in head-and-neck cancer survivors
- Medication-related osteonecrosis of the jaw (MRONJ) where the affected bone is the maxilla rather than the mandible
Mandibular cases look identical in the operating room, but they belong to CPT 21025. The operative note has to name the bone, every time.
Patient selection usually starts with failure of four to six weeks of intravenous or oral antibiotic therapy. Many patients arrive on referral from primary care with that treatment history already documented.
Surgeons then look for radiographic bone destruction, a sequestrum on CT or panoramic imaging, and persistent sinus tracts or exposed bone. Local Coverage Determinations (LCDs) from Medicare Administrative Contractors (MACs) may add further criteria. Check the applicable MAC policy before you submit.
CPT 21026 code details at a glance
The table below summarizes the data points billers need before submitting a CPT 21026 claim. RVU values come from the CY2025 Medicare Physician Fee Schedule (MPFS). Verify current-year figures with the CMS fee schedule lookup.
The work RVU is only one component of the payment. Practice expense and malpractice RVUs are added to it. The total is then multiplied by the year’s conversion factor, and geographic practice cost index (GPCI) values adjust it again for your locality. The CMS lookup returns both the facility and the non-facility total.
Medicare and payer reimbursement rates
Medicare payment for CPT 21026 depends on three variables. Those are the current MPFS conversion factor, the code’s total RVU value, and the GPCI-adjusted locality where the service is rendered.
Non-facility rates apply when the surgeon bills outside a hospital or ASC. They run higher because they include practice expense RVUs for overhead the provider carries directly.
For CPT 21026, the 2025 Medicare allowable generally falls between about $350 and $520 depending on locality. The highest rates sit in high-cost metro areas such as San Francisco, New York City, and Anchorage. Verify these figures against current CMS data before billing.
Commercial payers generally reimburse at a contracted percentage of Medicare, though rates vary by network and region. Confirm the allowed amount in your payer contract before quoting a patient on out-of-pocket costs.
ICD-10 diagnosis codes that support the claim
Medical necessity for CPT code 21026 depends on a diagnosis code that matches the documented site and condition. For the maxilla and the jaws, that code is M27.2. The ICD-10-CM alphabetic index routes jaw osteomyelitis there rather than to the M86 series.
The M86 other-site subcategories still have a role. Use them when the excised bone is a non-jaw facial bone, such as the zygoma, the orbital floor, or the nasal bones.
Match the subcategory to what the record actually says. Acute versus chronic, hematogenous versus other, and site specificity all decide which code applies. Infection of a bone graft placed at an earlier session codes to T86.832 instead. Check the current ICD-10-CM edition before submission.
Modifiers and CMS payment-policy indicators
Three CMS indicators decide which modifiers a CPT 21026 claim will accept. The bilateral surgery indicator is 0, the assistant-at-surgery indicator is 1, and the co-surgeons indicator is 0. Between them they rule out the two modifiers billers reach for most often on team and bilateral cases.
A bilateral indicator of 0 means the 150% payment adjustment does not apply. When 21026 is reported with modifier 50, Medicare pays the lower of the actual charge or 100% of the fee schedule amount.
An assistant-at-surgery indicator of 1 is a statutory restriction. Medicare will not pay an assistant surgeon on this code, so modifiers 80, 81, 82, and AS have nowhere to land. A co-surgeons indicator of 0 rules out modifier 62 in the same way.
Modifier 22 claims need an operative report that explains why the case was more work than typical. A note saying “complex case” is not enough. Quantify the extra time, describe the tissue condition, and reference the imaging findings.
Documentation requirements
Poor documentation drives most CPT 21026 denials and post-payment audits. Practices with HIPAA-compliant documentation and structured operative reporting hold up far better when auditors review surgical claims. Keeping clinical documentation in one system reduces the chance of a missing element at submission.
The operative report is the cornerstone document. It must include:
- Pre-operative diagnosis using the specific ICD-10-CM code that justifies the procedure, with the clinical findings that support it
- Operative findings naming the exact bone excised, such as the maxilla, zygoma, or orbital floor. Record the extent of necrosis, any sequestrum, and the condition of the surrounding soft tissue. The bone you name decides between CPT 21025 and 21026.
- Procedure performed stated in CPT descriptor language, meaning excision of bone for osteomyelitis or bone abscess. Avoid the word “debridement”, which maps to a different code family.
- Specimens sent to pathology where applicable, since the pathology report strengthens medical necessity. A separate open bone biopsy is CPT 20245 and is not reported when the excision itself supplies the specimen.
- Post-operative diagnosis confirming or refining the pre-operative diagnosis
Pre-operative imaging, either a CT scan or a panoramic radiograph, belongs in the record and should be referenced in the operative note. Auditors look for a clear chain of evidence. Imaging shows the bone destruction and the diagnosis code reflects that finding. The operative report then confirms the excision, and pathology supports it.
Pro Tip
Document the location, dimensions, and tissue quality of the excised bone before you close. A note reading ‘necrotic bone excised from the left maxilla, approximately 2cm x 1.5cm segment’ survives a records request. Add the margin detail too, such as granulation tissue removed to bleeding margins. A note that says ‘bone excised’ survives nothing.
NCCI edits and bundling rules
The National Correct Coding Initiative (NCCI) publishes quarterly edit tables that define which codes bundle with CPT 21026. Review the current tables through the CMS NCCI edit files before you submit a multi-code claim.
NCCI edit tables change every quarter, and the table above reflects general bundling principles. Confirm the current edits at the time of billing.
Prior authorization requirements
Medicare does not universally require prior authorization for CPT 21026, but many Medicare Advantage plans and commercial insurers do. Requirements change by plan year and payer, so never assume last year’s policy still holds.
When you submit a prior authorization request for CPT 21026, include the following clinical information:
- Current radiology report, either CT or panoramic X-ray, documenting bone destruction or necrosis
- Documentation of failed conservative management, with antibiotic start and end dates and the clinical response
- Surgical plan noting the extent of planned excision and the anticipated reconstruction approach
- Relevant lab results such as CBC, CRP, and ESR supporting active infection or treatment failure
- Supporting ICD-10-CM diagnosis codes matching the clinical findings
Common billing errors and how to avoid them
Most CPT 21026 denials are preventable. The errors below recur across practices and are exactly what RAC and MAC auditors look for during targeted reviews.
- Vague or unspecified ICD-10-CM codes: Using M86.9 instead of the site-specific code. Payers expect specificity, and unspecified codes trigger documentation requests or auto-denial.
- Coding a jaw case to the M86 series: Sending maxillary osteomyelitis to M86.68 when the index points to M27.2. The claim can survive, but the site specificity an auditor wants is missing.
- Miscoding excision as debridement: The debridement codes 97597-97598 and 11042-11047 describe wound debridement, not bone excision. Using one where the note documents excision is a compliance risk and a reimbursement loss.
- Appending a modifier CMS will not pay: Adding modifier 62, 80, or AS to a 21026 line. The payment-policy indicators rule both out, so the line denies and the claim needs a corrected resubmission.
- Incorrect place of service code: Billing office POS 11 for a procedure performed in a hospital, POS 21 or 22, or an ASC, POS 24. That miscalculates payment and exposes the practice to overpayment recovery.
- Billing 21026 for a mandibular excision: The mandible has its own code. Excision of mandibular bone for osteomyelitis or a bone abscess is CPT 21025, and 21026 covers the remaining facial bones.
- Insufficient operative note for a modifier 22 claim: Payers routinely request the records. They deny the modifier 22 add-on when the note does not quantify the increased work.
CPT 21026 vs. related facial bone surgery codes
Selecting the right facial bone code comes down to two questions. Which bone was operated on, and why. The error most likely to trigger an audit is reporting 21026 for a mandibular excision, which belongs to CPT 21025.
The second is reaching for an infection code when the indication was a tumor. A malignant mandibular lesion is CPT 21044, and a soft tissue mass of the face is CPT 21013.
Code selection follows the operative report. Name the bone that was excised and the reason it came out, and the choice between 21025 and 21026 settles itself. When a graft reconstructs the defect in the same session, report the graft separately. Never pick a code on reimbursement alone, because that is upcoding.
How Pabau keeps surgical coding and documentation in sync
Practices billing CPT 21026 run into the same three problems. Modifier selection happens under time pressure, prior authorization needs complete documentation for major surgical cases, and audit trails have to satisfy MAC reviewers. Systems that hold clinical notes apart from billing make all three harder.
Practice management software like Pabau closes that distance. Our claims management tools let surgical practices build modifier logic into claim templates and flag incomplete documentation before submission. Dictation and letters write the operative narrative straight into the patient record, so the note and the code never drift apart.
The payoff is fewer corrected claims and a shorter path from surgery to payment. Teams already running practice management software for scheduling and records can bring billing into the same platform. Compliance tools keep a central audit trail, so a records request does not turn into a week of searching.
Reduce CPT 21026 claim denials
Pabau's claims management tools help oral and maxillofacial surgery practices submit cleaner surgical claims. Modifier logic, documentation checks, and a central audit trail come built in.
Conclusion
CPT 21026 rewards precision about two things, anatomy and payment policy. Name the bone in the operative note and the choice between 21025 and 21026 settles itself.
The payment-policy indicators cause more trouble than the descriptor does. CMS pays no assistant surgeon, no co-surgeon, and no bilateral uplift on this code. Build those three checks into the claim template once, and they stop generating resubmissions.
The rest is documentation discipline. An operative note that names the bone, the extent of necrosis, and the specimen sent to pathology will carry the claim on its own. Book a demo to see how Pabau keeps surgical documentation and claim submission in one system.
Continue your research
Coding a mandibular osteotomy instead? CPT code 21196 walks through the RVUs, modifiers, and operative detail that orthognathic claims need.
Handling a midface trauma case? CPT code 21433 covers Le Fort III craniofacial separation repair and the documentation payers expect.
Need the rest of the M27 jaw block? ICD-10 code M27.0 explains developmental disorders of the jaws and when that subcategory applies.
Reconstructing the defect with a graft? CPT code 20902 sets out how major bone graft harvest is reported alongside an excision.
Operating on the temporomandibular joint? CPT code 21050 breaks down condylectomy billing, global period, and denial triggers.
Frequently asked questions
What is CPT code 21026 used for?
CPT code 21026 bills for surgical excision of bone of the facial skeleton, usually to remove necrotic or infected bone caused by osteomyelitis. It applies to facial bones other than the mandible, such as the maxilla, zygoma, or orbital floor. Excision of mandibular bone for the same indication is billed with CPT 21025.
What is the description of CPT code 21026?
The official AMA descriptor for CPT code 21026 is “Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s).” It sits in the musculoskeletal system section of the CPT manual, codes 21000-21499. Oral and maxillofacial surgeons, craniofacial surgeons, and head-and-neck specialists are its primary users.
What is the difference between CPT 21025 and CPT 21026?
The difference is anatomic site, not technique. CPT 21025 covers excision of bone of the mandible, and CPT 21026 covers excision of bone of the other facial bones. Both descriptors share the same indication, osteomyelitis or a bone abscess. Neither one includes a bone graft, which is reported separately with 21210 or 21215.
What is the Medicare reimbursement rate for CPT 21026?
Medicare reimbursement for CPT 21026 typically ranges from about $350 to $520. CMS assigns the code a work RVU of 5.70 under the CY2025 fee schedule. The exact allowable depends on the provider’s geographic locality and on the facility or non-facility setting. Rates change annually with the conversion factor, so verify current figures with the CMS lookup tool.
Can you bill an assistant surgeon with CPT 21026?
No. CMS assigns CPT 21026 an assistant-at-surgery indicator of 1, which is a statutory restriction. Medicare will not pay an assistant surgeon on this code, so modifiers 80, 81, 82, and AS will not hold. Co-surgery is ruled out too, because the co-surgeons indicator for 21026 is 0.
What documentation is required to bill CPT 21026?
Billing CPT 21026 requires an operative report covering the pre-operative diagnosis and the intraoperative findings. Those findings should name the bone excised, the extent of necrosis, and any sequestrum. The report also needs the procedure stated in CPT descriptor language, plus the post-operative diagnosis. Supporting imaging and, where obtained, a pathology report should be in the record.
What modifiers apply to CPT code 21026?
The modifiers used most often with CPT 21026 are 50, 22, 59, and 78. Modifier 50 covers a bilateral procedure, though CMS pays no 150% uplift on this code. Modifier 22 flags increased complexity, and modifier 59 overrides an NCCI edit. Modifier 78 covers an unplanned return to the operating room inside the 90-day global period. Modifier 62 does not apply, because CMS does not permit co-surgeons on 21026.
Which ICD-10 code pairs with CPT 21026 for jaw osteomyelitis?
Use M27.2, inflammatory conditions of jaws. The ICD-10-CM alphabetic index routes jaw and maxillary osteomyelitis to M27.2 rather than to the M86 series. Reserve the M86 other-site subcategories for non-jaw facial bones such as the zygoma, orbital floor, and nasal bones. Medication-related osteonecrosis of the jaw codes to M87.180.
Is CPT 21026 subject to prior authorization?
Traditional Medicare does not universally require prior authorization for CPT 21026. Many Medicare Advantage plans and commercial insurers do require it for inpatient or ASC surgical procedures. Check the payer’s current requirements before scheduling. Submit imaging, antibiotic failure records, and lab results to support the medical necessity determination.
