CPT code 21125 is a medical code used to describe the surgical procedure for augmenting the lower jaw bone.
CPT code 21125 is used for a surgical procedure that involves augmenting or adding to the lower jaw bone. This typically means that the surgeon is increasing the size or reshaping the lower jaw bone, often using grafts or implants, to improve function or appearance.
For CPT code 21125 (Augmentation lower jaw bone), 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 perform the procedure is substantially greater than typically required.
2. Modifier 50 - Bilateral Procedure: Used if the procedure is performed on both sides of the body.
3. Modifier 51 - Multiple Procedures: Used when multiple procedures are performed during the same surgical session.
4. Modifier 52 - Reduced Services: Used when a service or procedure is partially reduced or eliminated at the physician's discretion.
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.
6. Modifier 62 - Two Surgeons: Used when two surgeons work together as primary surgeons performing distinct parts of a procedure.
7. Modifier 76 - Repeat Procedure by Same Physician: Used when the same procedure is repeated by the same physician.
8. Modifier 77 - Repeat Procedure by Another Physician: Used when the same procedure is repeated by another physician.
9. 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 when a related procedure is performed during the postoperative period of the initial procedure.
10. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Used when an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
11. Modifier 80 - Assistant Surgeon: Used when an assistant surgeon is required during the procedure.
12. Modifier 81 - Minimum Assistant Surgeon: Used when a minimum assistant surgeon is required during the procedure.
13. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Used when an assistant surgeon is required and a qualified resident surgeon is not available.
14. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: Used when a PA, NP, or CNS assists in the surgery.
These modifiers help provide additional information about the circumstances of the procedure and ensure accurate billing and reimbursement. Always verify with the latest coding guidelines and payer-specific requirements.
Medicare Reimbursement for CPT Code 21125: Augmentation Lower Jaw Bone
CPT code 21125 pertains to the surgical procedure for the augmentation of the lower jaw bone. Whether Medicare reimburses this code depends on several factors, including the medical necessity of the procedure and the specific circumstances of the patient.
Medicare typically covers procedures that are deemed medically necessary. For CPT code 21125, this means that the augmentation of the lower jaw bone must be essential for the patient's health, such as in cases of significant jaw deformities or reconstruction following trauma or disease.
To determine if Medicare will reimburse for CPT code 21125 in a specific case, healthcare providers should:
1. Verify Medical Necessity: Ensure that the procedure is documented as medically necessary. This often requires thorough documentation and possibly pre-authorization.
2. Check Local Coverage Determinations (LCDs): Medicare Administrative Contractors (MACs) may have specific guidelines or Local Coverage Determinations (LCDs) that outline the criteria for coverage of this procedure.
3. Submit Accurate Claims: Ensure that the claim is submitted with all necessary documentation and coding to support the medical necessity of the procedure.
As for the reimbursement amount, it can vary based on geographic location, the specific Medicare plan, and other factors. Generally, Medicare reimbursement rates are determined by the Medicare Physician Fee Schedule (MPFS). Providers can look up the specific reimbursement rate for CPT code 21125 using the MPFS Look-Up Tool available on the Centers for Medicare & Medicaid Services (CMS) website.
In summary, Medicare may reimburse CPT code 21125 if the procedure is medically necessary and all required documentation is provided. For the exact reimbursement amount, providers should refer to the MPFS or consult with their local MAC.
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 21125 for augmentation of the lower jaw bone. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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