CPT code 20938 is a code used to describe the procedure of adding a structural bone graft during surgery.
CPT code 20938 is used for reporting a structural allograft, which is an additional procedure involving the use of donor bone tissue to support or replace damaged bone in a patient. This code is considered an add-on, meaning it is used in conjunction with another primary procedure code to indicate that the structural bone graft was performed as part of a more extensive surgical intervention.
When using CPT code 20938 for "Sp bone agrft struct add-on," several modifiers may be applicable depending on the specific circumstances of the procedure. Below is a list of potential modifiers and the reasons for their use:
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 51 - Multiple Procedures
- Apply this modifier when multiple procedures are performed during the same surgical session. This indicates that the procedure is one of several performed on the same day.
3. Modifier 59 - Distinct Procedural Service
- Use this modifier to indicate that the procedure is distinct or independent from other services performed on the same day. This is particularly relevant if the bone graft is performed in a different anatomical site or through a separate incision.
4. Modifier 62 - Two Surgeons
- This modifier is used when two surgeons work together as primary surgeons performing distinct parts of a single reportable procedure. Each surgeon should report their distinct operative work.
5. Modifier 76 - Repeat Procedure by Same Physician
- Use this modifier if the same physician needs to repeat the procedure on the same day. This indicates that the repeat procedure was necessary and performed by the same provider.
6. Modifier 77 - Repeat Procedure by Another Physician
- Apply this modifier when a procedure needs to be repeated on the same day by a different physician. This helps to clarify that the repeat procedure was necessary and performed by another provider.
7. 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 needs to return to the operating room for a related procedure during the postoperative period of the initial surgery.
8. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- This modifier is used when an unrelated procedure is performed by the same physician during the postoperative period of the initial surgery.
9. Modifier 80 - Assistant Surgeon
- Apply this modifier when an assistant surgeon is required to help with the procedure. This indicates that another surgeon assisted in the operation.
10. Modifier 81 - Minimum Assistant Surgeon
- Use this modifier when an assistant surgeon is required for a minimal portion of the procedure.
11. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- This modifier is used when an assistant surgeon is necessary because a qualified resident surgeon is not available.
12. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Apply this modifier when a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery.
Each of these modifiers serves a specific purpose and helps to provide a clearer picture of the services rendered, ensuring accurate billing and reimbursement. Always ensure that documentation supports the use of any modifier to avoid claim denials or audits.
Medicare reimbursement for CPT code 20938, which refers to "Sp bone agrft struct add-on," can vary based on several factors, including the specific Medicare Administrative Contractor (MAC) jurisdiction, the setting in which the procedure is performed, and the patient's specific circumstances. Generally, add-on codes like 20938 are reimbursed by Medicare when they are billed in conjunction with a primary procedure that is covered.
To determine the exact reimbursement amount for CPT code 20938, you would need to refer to the Medicare Physician Fee Schedule (MPFS) or the specific MAC's fee schedule for the relevant year. These resources provide detailed information on the allowable amounts for various CPT codes. Additionally, the reimbursement amount can be influenced by geographic location due to the Geographic Practice Cost Index (GPCI) adjustments.
For the most accurate and up-to-date information, healthcare providers should consult the MPFS or contact their local MAC.
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