CPT code 21076 is for preparing a face/oral prosthesis, detailing the specific medical service provided for accurate billing and documentation.
CPT code 21076 is used for the preparation of a face or oral prosthesis. This involves the creation and fitting of a custom-made artificial device designed to replace missing facial or oral structures, often due to surgery, injury, or congenital conditions.
When billing for CPT code 21076 (Prepare face/oral prosthesis), it is essential to use the appropriate modifiers to ensure accurate reimbursement and compliance with payer requirements. Below is a list of potential modifiers that could be used with CPT code 21076, along with the reasons for their use:
1. Modifier 22 - Increased Procedural Services
- Use this modifier if the work required to prepare the face/oral prosthesis is substantially greater than typically required.
2. Modifier 52 - Reduced Services
- Apply this modifier if the service provided was partially reduced or eliminated at the physician's discretion.
3. Modifier 53 - Discontinued Procedure
- Use this modifier if the procedure was started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
4. Modifier 59 - Distinct Procedural Service
- This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day.
5. Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
- Use this modifier if the same procedure was repeated by the same provider on the same day.
6. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional
- Apply this modifier if the same procedure was repeated by a different provider on the same day.
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.
8. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- Apply this modifier if an unrelated procedure is performed by the same provider during the postoperative period of the initial procedure.
9. Modifier 80 - Assistant Surgeon
- Use this modifier if an assistant surgeon was required during the procedure.
10. Modifier 81 - Minimum Assistant Surgeon
- Apply this modifier if a minimum assistant surgeon was required during the procedure.
11. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Use this modifier if an assistant surgeon was required because a qualified resident surgeon was not available.
12. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Apply this modifier if a physician assistant, nurse practitioner, or clinical nurse specialist assisted in the surgery.
13. Modifier LT - Left Side
- Use this modifier if the procedure was performed on the left side of the face/oral area.
14. Modifier RT - Right Side
- Apply this modifier if the procedure was performed on the right side of the face/oral area.
15. Modifier GC - This Service Has Been Performed in Part by a Resident Under the Direction of a Teaching Physician
- Use this modifier if the service was performed in part by a resident under the supervision of a teaching physician.
16. Modifier QX - CRNA Service: With Medical Direction by a Physician
- Apply this modifier if a Certified Registered Nurse Anesthetist (CRNA) provided the service under the medical direction of a physician.
17. Modifier QY - Medical Direction of One CRNA by an Anesthesiologist
- Use this modifier if an anesthesiologist provided medical direction for one CRNA.
18. Modifier QK - Medical Direction of Two, Three, or Four Concurrent Anesthesia Procedures Involving Qualified Individuals
- Apply this modifier if an anesthesiologist provided medical direction for two to four concurrent anesthesia procedures.
19. Modifier QS - Monitored Anesthesia Care Service
- Use this modifier if monitored anesthesia care was provided during the procedure.
20. Modifier G8 - Monitored Anesthesia Care (MAC) for Deep Complex, Complicated, or markedly invasive surgical procedure
- Apply this modifier if monitored anesthesia care was provided for a deep, complex, or markedly invasive surgical procedure.
21. Modifier G9 - Monitored Anesthesia Care for Patient who has a history of severe cardiopulmonary condition
- Use this modifier if monitored anesthesia care was provided for a patient with a history of severe cardiopulmonary condition.
By using the appropriate modifiers, healthcare providers can ensure that their claims for CPT code 21076 are processed accurately and efficiently, leading to proper reimbursement and compliance with payer guidelines.
Medicare reimbursement for CPT code 21076, which pertains to the preparation of a face/oral prosthesis, can vary based on several factors including the specific Medicare plan, the setting in which the service is provided, and the medical necessity as documented by the healthcare provider. Generally, Medicare Part B may cover prosthetic devices if they are deemed medically necessary and prescribed by a physician. However, the reimbursement amount can differ.
As of the latest available data, the national average reimbursement rate for CPT code 21076 under Medicare is approximately $1,200. It's important to verify this amount with the most current Medicare fee schedule, as rates are subject to change. Additionally, providers should ensure that all necessary documentation is in place to support the medical necessity of the procedure to facilitate smooth reimbursement.
Discover how MD Clarity's RevFind software can meticulously analyze your contracts and identify underpayments down to the CPT code level, including specific codes like 21076 for preparing face/oral prostheses. Ensure you're receiving accurate reimbursements from every payer. Schedule a demo today to see RevFind in action and protect your revenue.
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