CPT code 21040 is a medical billing code used to describe the procedure of excising a lesion from the mandible.
CPT code 21040 is used to describe the surgical procedure for the excision, or removal, of a lesion from the mandible, which is the lower jawbone. This code is specifically for cases where a lesion, such as a cyst or tumor, needs to be surgically removed from the mandible.
For CPT code 21040 (Excise mandible lesion), the following modifiers may be applicable depending on the specific circumstances of the procedure:
1. Modifier 22 - Increased Procedural Services: Used when the work required to provide a service is substantially greater than typically required. This could apply if the excision of the mandible lesion is more complex than usual.
2. Modifier 50 - Bilateral Procedure: Used if the procedure is performed on both sides of the mandible.
3. Modifier 51 - Multiple Procedures: Used when multiple procedures are performed during the same surgical session. This could apply if other surgical procedures are performed in addition to the excision of the mandible lesion.
4. Modifier 52 - Reduced Services: Used when a service or procedure is partially reduced or eliminated at the physician's discretion. This could apply if the excision is less extensive than planned.
5. Modifier 59 - Distinct Procedural Service: Used to indicate that a procedure or service was distinct or independent from other services performed on the same day. This could apply if the excision of the mandible lesion is performed in conjunction with other procedures that are not typically performed together.
6. Modifier 76 - Repeat Procedure by Same Physician: Used if the same procedure is repeated by the same physician. This could apply if the excision needs to be repeated due to recurrence or incomplete initial excision.
7. Modifier 77 - Repeat Procedure by Another Physician: Used if the same procedure is repeated by a different physician. This could apply if the excision needs to be repeated by another provider.
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: Used if the patient needs to return to the operating room for a related procedure during the postoperative period.
9. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Used if an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
10. Modifier 80 - Assistant Surgeon: Used if an assistant surgeon is required during the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: Used if a minimum assistant surgeon is required during the procedure.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Used if 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: Used if a non-physician provider assists in the surgery.
Each of these modifiers serves a specific purpose and should be used accurately to ensure proper billing and reimbursement for the services provided.
Medicare reimbursement for CPT code 21040, which pertains to the excision of a lesion on the mandible, depends on several factors including the medical necessity of the procedure, the setting in which it is performed, and the patient's specific Medicare plan. Generally, Medicare Part B may cover this procedure if it is deemed medically necessary and performed in an outpatient setting. However, the exact reimbursement amount can vary based on geographic location and other factors.
To determine the specific reimbursement amount for CPT code 21040, healthcare providers can refer to the Medicare Physician Fee Schedule (MPFS) or use the Medicare Administrative Contractor (MAC) lookup tools. As of the latest update, the national average reimbursement for CPT code 21040 is approximately $400, but this figure can fluctuate. Providers should verify the current rates and guidelines through official Medicare resources or their MAC.
For the most accurate and up-to-date information, it is advisable to consult the Medicare Physician Fee Schedule or contact your local Medicare Administrative Contractor.
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