CPT code 21086 is for preparing a face/oral prosthesis, detailing the medical procedure for creating a custom prosthetic device.
CPT code 21086 is used for the preparation of a face or oral prosthesis. This involves creating a custom-made artificial device to replace or cover parts of the face or mouth, typically due to injury, surgery, or congenital conditions.
When billing for CPT code 21086 (Prepare face/oral prosthesis), it is essential to consider the appropriate use of modifiers to ensure accurate reimbursement and compliance with payer requirements. Below is a list of potential modifiers that could be used with CPT code 21086, along with the reasons for their use:
1. Modifier 22 - Increased Procedural Services
- Use this modifier if the procedure required significantly more work than typically required. Documentation must support the additional effort.
2. Modifier 52 - Reduced Services
- Apply this modifier if the procedure was partially reduced or eliminated at the physician's discretion. Documentation should clearly indicate the reason for the reduction.
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. It is often used to bypass National Correct Coding Initiative (NCCI) edits.
5. Modifier 76 - Repeat Procedure by Same Physician
- Use this modifier if the same physician repeats the procedure on the same day.
6. Modifier 77 - Repeat Procedure by Another Physician
- Apply this modifier if a different physician repeats the procedure 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
- This modifier is used when the patient returns to the operating room for a related procedure during the postoperative period of the initial procedure.
8. 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.
9. Modifier 80 - Assistant Surgeon
- Apply this modifier if an assistant surgeon was required for the procedure.
10. Modifier 81 - Minimum Assistant Surgeon
- Use this modifier if a minimum assistant surgeon was required for the procedure.
11. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- This modifier is used when an assistant surgeon is required 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 if a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery.
13. Modifier LT - Left Side
- Use this modifier to indicate that the procedure was performed on the left side of the body.
14. Modifier RT - Right Side
- Apply this modifier to indicate that the procedure was performed on the right side of the body.
15. Modifier 99 - Multiple Modifiers
- Use this modifier when multiple modifiers are necessary to describe the service provided. Documentation should clearly indicate the use of each modifier.
Proper use of these modifiers can help ensure that claims are processed correctly and that the healthcare provider receives appropriate reimbursement for the services rendered. Always refer to the latest coding guidelines and payer-specific requirements when applying modifiers.
Medicare reimbursement for CPT code 21086, which pertains to the preparation of a face/oral prosthesis, is contingent upon several factors, including medical necessity, the specific circumstances of the patient's condition, and the setting in which the service is provided. Generally, Medicare Part B may cover prosthetic devices if they are deemed medically necessary and prescribed by a physician.
However, the exact reimbursement amount for CPT code 21086 can vary based on geographic location, the specific Medicare Administrative Contractor (MAC), and other factors such as whether the service is performed in a hospital outpatient setting or a physician's office. To determine the precise reimbursement rate, healthcare providers should refer to the Medicare Physician Fee Schedule (MPFS) or contact their local MAC.
For the most accurate and up-to-date information, providers can use the Medicare Fee Schedule Lookup Tool available on the Centers for Medicare & Medicaid Services (CMS) website or consult with their billing department to ensure compliance and proper reimbursement.
Discover how MD Clarity's RevFind software can meticulously analyze your contracts and pinpoint underpayments down to the CPT code level, including specific codes like 21086 for preparing face/oral prostheses. Schedule a demo today to see how RevFind can help you identify and recover revenue from individual payers.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
