CPT code 21195 is a medical code used to describe the reconstruction of the lower jaw without fixation.
CPT code 21195 is for the surgical reconstruction of the lower jaw without the use of fixation devices. This procedure typically involves reshaping or rebuilding the jawbone to correct deformities or injuries, but it does not include the use of plates, screws, or other hardware to hold the bone in place.
When billing for CPT code 21195 (Reconstruction of lower jaw without fixation), 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 21195, 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. This could be due to factors such as increased complexity, time, or technical difficulty.
2. Modifier 50 - Bilateral Procedure
- Apply this modifier if the procedure was performed on both sides of the lower jaw during the same operative session.
3. Modifier 51 - Multiple Procedures
- Use this modifier when multiple procedures are performed during the same surgical session. This indicates that more than one procedure was carried out, which may affect reimbursement.
4. Modifier 52 - Reduced Services
- This modifier is used when the procedure is partially reduced or eliminated at the physician's discretion. It indicates that the full service described by the CPT code was not performed.
5. Modifier 59 - Distinct Procedural Service
- Apply this modifier to indicate that the procedure was distinct or independent from other services performed on the same day. This is often used to bypass National Correct Coding Initiative (NCCI) edits.
6. Modifier 62 - Two Surgeons
- Use this modifier when two surgeons work together as primary surgeons performing distinct parts of the procedure. Each surgeon should report their distinct operative work.
7. Modifier 66 - Surgical Team
- This modifier is used when a highly complex procedure requires the services of several physicians, often of different specialties, working together as a team.
8. Modifier 76 - Repeat Procedure by Same Physician
- Apply this modifier if the same physician needs to repeat the procedure on the same day due to complications or other reasons.
9. Modifier 77 - Repeat Procedure by Another Physician
- Use this modifier if a different physician needs to repeat the procedure on the same day.
10. 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 requires an unplanned return to the operating room for a related procedure during the postoperative period.
11. 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 physician during the postoperative period of the initial procedure.
12. Modifier 80 - Assistant Surgeon
- Use this modifier when an assistant surgeon is required to assist the primary surgeon during the procedure.
13. Modifier 81 - Minimum Assistant Surgeon
- This modifier is used when an assistant surgeon provides minimal assistance during the procedure.
14. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Apply this modifier when an assistant surgeon is necessary because a qualified resident surgeon is not available.
15. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Use this modifier when a non-physician provider assists in the surgery.
Each modifier serves a specific purpose and should be used appropriately to reflect the circumstances of the procedure accurately. Proper use of modifiers ensures that claims are processed correctly and that the healthcare provider receives appropriate reimbursement for the services rendered.
Medicare reimbursement for CPT code 21195, which pertains to the reconstruction of the lower jaw without fixation, depends on several factors, including the specific Medicare plan, the medical necessity of the procedure, and the setting in which the service is provided. Generally, Medicare Part B may cover this procedure if it is deemed medically necessary and performed by a qualified healthcare provider. However, the reimbursement amount can vary based on geographic location, the provider's fee schedule, and other considerations.
As of the latest available data, the national average reimbursement rate for CPT code 21195 under Medicare Part B is approximately $1,200. However, this amount is subject to change and may differ based on local adjustments and specific circumstances. Providers should verify the exact reimbursement rate through the Medicare Physician Fee Schedule (MPFS) or consult with their Medicare Administrative Contractor (MAC) for the most accurate and up-to-date information.
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 21195 for reconstructing the lower jaw without fixation. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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