CPT code 12055 is for intermediate repair of face/mucous membrane wounds measuring 12.6-20 cm.
CPT code 12055 is used for an intermediate repair of a wound on the face, ears, eyelids, nose, lips, or mucous membranes that measures between 12.6 to 20 centimeters. This code indicates that the repair involves layered closure of one or more of the deeper layers of subcutaneous tissue and superficial fascia, in addition to the skin closure.
When using CPT code 12055, the following modifiers may be applicable depending on the specific circumstances of the procedure:
1. Modifier 22 - Increased Procedural Services: Use this modifier if the work required to perform the procedure is substantially greater than typically required. Documentation must support the substantial additional work and the reason for it.
2. Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: Use this modifier if a significant, separately identifiable E/M service is performed by the same physician on the same day as the procedure.
3. Modifier 51 - Multiple Procedures: Use this modifier when multiple procedures are performed during the same session. This indicates that the procedure is one of several performed on the same day.
4. Modifier 52 - Reduced Services: Use this modifier when a service or procedure is partially reduced or eliminated at the physician's discretion.
5. Modifier 59 - Distinct Procedural Service: Use this modifier to indicate that a procedure or service was distinct or independent from other services performed on the same day. This is often used to identify procedures that are not typically reported together but are appropriate under the circumstances.
6. Modifier 76 - Repeat Procedure or Service by Same Physician: Use this modifier if the same procedure is repeated by the same physician subsequent to the original procedure.
7. Modifier 77 - Repeat Procedure by Another Physician: Use this modifier if the same procedure is repeated by a different physician subsequent to the original procedure.
8. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: Use this modifier if the patient returns to the operating room for a related procedure during the postoperative period of the initial procedure.
9. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Use this modifier if an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
10. Modifier 80 - Assistant Surgeon: Use this modifier when an assistant surgeon is required for the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: Use this modifier when a minimum assistant surgeon is required for the procedure.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Use this modifier when an assistant surgeon is required, and a qualified resident surgeon is not available.
13. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery: Use this modifier when a PA, NP, or CNS assists in the surgery.
Each modifier serves a specific purpose and should be used in accordance with the guidelines to ensure accurate billing and reimbursement. Proper documentation is essential to support the use of any modifier.
When determining if CPT code 12055 is reimbursed by Medicare, it is essential to consult the Medicare Physician Fee Schedule (MPFS) and the guidelines provided by your regional Medicare Administrative Contractor (MAC). The MPFS is a comprehensive listing of the payment rates used by Medicare to reimburse physicians and other healthcare providers for services rendered. Each MAC, which administers Medicare claims for a specific region, may have additional local coverage determinations (LCDs) that affect reimbursement.
To verify if CPT code 12055 is reimbursed, you should:
1. Check the MPFS: Access the MPFS database to see if CPT code 12055 is listed and review the associated reimbursement rates.
2. Consult Your MAC: Review any LCDs or other guidance documents issued by your MAC to ensure there are no specific regional restrictions or additional documentation requirements for CPT code 12055.
By following these steps, you can determine if CPT code 12055 is reimbursed by Medicare and understand any specific conditions or requirements that may apply.
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