CPT code 21235 is a medical code used to describe the procedure of an ear cartilage graft.
CPT code 21235 is used for a procedure involving an ear cartilage graft. This means that the healthcare provider takes cartilage from the ear and uses it as a graft to repair or reconstruct another part of the body.
For CPT code 21235 (Ear cartilage graft), 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 ear cartilage graft is performed on both ears during the same operative session.
3. Modifier 51 - Multiple Procedures: Used when multiple procedures are performed during the same surgical session.
4. Modifier 52 - Reduced Services: Used when the 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 76 - Repeat Procedure by Same Physician: Used if the same procedure is repeated by the same physician.
7. Modifier 77 - Repeat Procedure by Another Physician: Used if the same procedure is repeated by a different physician.
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 when a related procedure is performed during the postoperative period of the initial procedure.
9. 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.
10. Modifier 80 - Assistant Surgeon: Used when an assistant surgeon is required during the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: Used when a minimum assistant surgeon is required during the procedure.
12. 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.
13. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: Used when these non-physician practitioners assist in the surgery.
Each modifier serves a specific purpose and should be used accurately to ensure proper billing and reimbursement. Always refer to the latest CPT and payer guidelines for the most current and applicable modifiers.
Medicare reimbursement for CPT code 21235, which pertains to an ear cartilage graft, depends on several factors including medical necessity, the setting in which the procedure is performed, and the specific Medicare Administrative Contractor (MAC) policies in your region.
Generally, Medicare does reimburse for CPT code 21235 if the procedure is deemed medically necessary. Medical necessity is typically determined based on the patient's condition and the documentation provided by the healthcare provider. It is crucial to ensure that all documentation supports the necessity of the procedure to avoid claim denials.
The reimbursement amount for CPT code 21235 can vary. As of the latest available data, the national average reimbursement rate for this code under the Medicare Physician Fee Schedule (MPFS) is approximately $500. However, this amount can fluctuate based on geographic location, the specific MAC, and any applicable adjustments or modifiers.
For the most accurate and up-to-date reimbursement information, healthcare providers should consult the Medicare Physician Fee Schedule Look-Up Tool or contact their local MAC. This will provide the specific reimbursement rates and any additional guidelines pertinent to their region.
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 21235 for ear cartilage grafts. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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