CPT code 21365 is for the open treatment of a complex malar fracture, involving surgical intervention to repair the cheekbone.
CPT code 21365 is for the open treatment of a complex malar (cheekbone) fracture. This involves surgically exposing the fracture site to properly align and fix the broken bones in the cheek area.
When billing for CPT code 21365 (Open treatment of complicated malar fracture), 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 the complexity of the fracture or patient-specific factors.
2. Modifier 51 - Multiple Procedures: If multiple procedures were performed during the same surgical session, this modifier should be appended to indicate that more than one procedure was carried out.
3. Modifier 52 - Reduced Services: If the procedure was partially reduced or eliminated at the physician's discretion, this modifier should be used.
4. Modifier 58 - Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: Use this modifier if the procedure was planned or anticipated (staged) or was more extensive than the original procedure.
5. 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.
6. Modifier 62 - Two Surgeons: If two surgeons worked together as primary surgeons performing distinct parts of the procedure, this modifier should be used.
7. Modifier 76 - Repeat Procedure or Service by Same Physician: If the same procedure was repeated by the same physician, this modifier should be appended.
8. Modifier 77 - Repeat Procedure by Another Physician: If the procedure was repeated by a different physician, this modifier should be used.
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: This modifier is used if the patient required an unplanned return to the operating room for a related procedure.
10. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Use this modifier if an unrelated procedure was performed by the same physician during the postoperative period.
11. Modifier 80 - Assistant Surgeon: If an assistant surgeon was required during the procedure, this modifier should be appended.
12. Modifier 81 - Minimum Assistant Surgeon: Use this modifier if a minimum assistant surgeon was required.
13. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): This modifier is used when an assistant surgeon is necessary because a qualified resident surgeon is not available.
14. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery: This modifier is 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 coding guidelines and payer-specific requirements when applying modifiers.
Medicare reimbursement for CPT code 21365, which refers to the open treatment of a complex malar (cheekbone) fracture, depends on several factors including the specific Medicare plan, the geographic location of the service, and whether the procedure is deemed medically necessary. Generally, Medicare Part B covers medically necessary surgical procedures, and CPT code 21365 would typically fall under this category.
As of the latest available data, the national average reimbursement rate for CPT code 21365 under Medicare is approximately $1,200. However, this amount can vary based on the Medicare Physician Fee Schedule (MPFS) and regional adjustments. Providers should verify the exact reimbursement rate through the Medicare Administrative Contractor (MAC) for their specific region and ensure that all documentation supports the medical necessity of the procedure to facilitate proper reimbursement.
For the most accurate and up-to-date information, healthcare providers should consult the latest MPFS and 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 21365 for open treatment of complex malar fractures. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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