CPT code 21355 is a medical code used to describe the procedure for treating a malar (cheekbone) fracture.
CPT code 21355 is for the treatment of a malar (cheekbone) fracture. This code is used when a healthcare provider performs a procedure to repair or manage a broken cheekbone.
When billing for CPT code 21355 (Perq tx malar fracture), 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 21355, 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 complications or unusual circumstances.
2. Modifier 24 - Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period
- Apply this modifier if an unrelated E/M service is performed during the postoperative period of the initial procedure.
3. Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
- Use this modifier if a significant, separately identifiable E/M service is provided on the same day as the procedure.
4. Modifier 50 - Bilateral Procedure
- Use this modifier if the procedure is performed bilaterally.
5. Modifier 51 - Multiple Procedures
- Apply this modifier if multiple procedures are performed during the same session.
6. Modifier 52 - Reduced Services
- Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion.
7. Modifier 53 - Discontinued Procedure
- Apply this modifier if the procedure was discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
8. Modifier 54 - Surgical Care Only
- Use this modifier if the physician performed only the surgical portion of the procedure.
9. Modifier 55 - Postoperative Management Only
- Apply this modifier if the physician provided only the postoperative care.
10. Modifier 56 - Preoperative Management Only
- Use this modifier if the physician provided only the preoperative care.
11. Modifier 59 - Distinct Procedural Service
- Apply this modifier to indicate that a procedure or service was distinct or independent from other services performed on the same day.
12. Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
- Use this modifier if the same procedure is repeated by the same physician.
13. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional
- Apply this modifier if the same procedure is repeated by a different physician.
14. 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 returns to the operating room for a related procedure during the postoperative period.
15. 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.
16. Modifier 80 - Assistant Surgeon
- Use this modifier if an assistant surgeon was required for the procedure.
17. Modifier 81 - Minimum Assistant Surgeon
- Apply this modifier if a minimum assistant surgeon was required for the procedure.
18. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Use this modifier if an assistant surgeon was required because a qualified resident surgeon was not available.
19. 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 assisted in the surgery.
By appropriately applying these modifiers, healthcare providers can ensure accurate billing and optimize reimbursement for CPT code 21355.
Determining whether a specific CPT code, such as 21355 (Perq tx malar fracture), is reimbursed by Medicare involves several steps. Medicare reimbursement for CPT codes depends on various factors, including the setting in which the service is provided, the patient's specific Medicare plan, and whether the service is deemed medically necessary.
For CPT code 21355, which pertains to the percutaneous treatment of a malar (cheekbone) fracture, Medicare typically provides reimbursement if the procedure is medically necessary and properly documented. However, the exact reimbursement amount can vary based on geographic location, the specific Medicare Administrative Contractor (MAC) overseeing the claim, and other factors such as the facility type (hospital, outpatient clinic, etc.).
To determine the precise reimbursement amount for CPT code 21355, healthcare providers can refer to the Medicare Physician Fee Schedule (MPFS) or use the Medicare Fee Schedule Lookup Tool available on the Centers for Medicare & Medicaid Services (CMS) website. Additionally, providers can contact their local MAC for the most accurate and up-to-date information.
In summary, while Medicare generally reimburses CPT code 21355 if it meets the necessary criteria, the exact reimbursement amount should be verified through official Medicare resources or the local MAC.
Discover how MD Clarity's RevFind software can meticulously analyze your contracts and identify underpayments down to the CPT code level, including specific codes like 21355 for perq tx malar fracture. Ensure you're receiving the full reimbursement you deserve from every payer. Schedule a demo today to see RevFind in action and protect your revenue.
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