CPT code 21246 is for the surgical reconstruction of the jaw, detailing the specific medical procedure for accurate billing and documentation.
CPT code 21246 is for the surgical procedure involving the reconstruction of the jaw. This code is used when a healthcare provider performs a complex surgery to rebuild or repair the jawbone, often due to trauma, congenital defects, or disease. The procedure may involve grafting bone or using other materials to restore the jaw's structure and function.
For CPT code 21246 (Reconstruction of jaw), the following modifiers may be applicable:
1. Modifier 22 - Increased Procedural Services: Use this modifier if the procedure required significantly more work than typically required. This could be due to complications or the complexity of the patient's condition.
2. Modifier 52 - Reduced Services: Apply this modifier if the procedure 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 62 - Two Surgeons: If two surgeons are required to perform the procedure due to its complexity, this modifier should be used.
6. Modifier 66 - Surgical Team: Apply this modifier if the procedure requires a surgical team due to its complexity.
7. Modifier 76 - Repeat Procedure by Same Physician: Use this modifier if the same physician needs to repeat the procedure.
8. Modifier 77 - Repeat Procedure by Another Physician: Apply this modifier if a different physician needs to repeat the procedure.
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: Use this modifier if the patient needs to return to the operating room for a related procedure during the postoperative period.
10. 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.
11. Modifier 80 - Assistant Surgeon: Use this modifier if an assistant surgeon is required for the procedure.
12. Modifier 81 - Minimum Assistant Surgeon: Apply this modifier if a minimum assistant surgeon is required for the procedure.
13. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Use this modifier if 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: Apply this modifier if a non-physician provider assists in the surgery.
15. Modifier LT - Left Side: Use this modifier if the procedure is performed on the left side of the body.
16. Modifier RT - Right Side: Apply this modifier if the procedure is performed on the right side of the body.
17. Modifier 99 - Multiple Modifiers: Use this modifier if multiple modifiers are needed for the procedure.
These modifiers help provide additional information about the circumstances of the procedure and ensure accurate billing and reimbursement.
Medicare reimbursement for CPT code 21246, which pertains to the reconstruction of the jaw, is contingent upon several factors including medical necessity, the specific Medicare plan, and the setting in which the procedure is performed. Generally, Medicare Part B may cover this procedure if it is deemed medically necessary and is performed in an outpatient setting. However, the reimbursement amount can vary based on geographic location and other variables.
As of the latest available data, the national average reimbursement rate for CPT code 21246 under Medicare is approximately $1,200 to $1,500. It is important to verify the exact reimbursement rate through the Medicare Physician Fee Schedule (MPFS) or consult with your Medicare Administrative Contractor (MAC) for the most accurate and up-to-date information.
Healthcare providers should ensure proper documentation and justification of medical necessity to facilitate smooth reimbursement processes.
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 21246 for jaw reconstruction. Schedule a demo today to see how RevFind can help you identify and recover lost revenue from individual payers.
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