CPT code 21366 is for the open treatment of a complex malar fracture with graft.
CPT code 21366 is for the open treatment of a complex fracture of the malar (cheek) bone, which includes the use of a graft to repair the fracture. This procedure is typically performed by a surgeon to ensure proper alignment and healing of the cheekbone.
When billing for CPT code 21366 (Open treatment of complex malar fracture, including internal fixation and bone grafting, when performed), several modifiers may be applicable depending on the specific circumstances of the procedure. Below is a list of potential modifiers and the reasons for their use:
1. Modifier 22 - Increased Procedural Services
- Use this modifier if the procedure required significantly greater effort or complexity than typically required.
2. Modifier 50 - Bilateral Procedure
- Apply this modifier if the procedure was performed on both sides of the body.
3. Modifier 51 - Multiple Procedures
- Use this modifier when multiple procedures are performed during the same surgical session.
4. Modifier 52 - Reduced Services
- Apply this modifier if the procedure was partially reduced or eliminated at the physician's discretion.
5. 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 more extensive than the original procedure.
6. 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.
7. Modifier 62 - Two Surgeons
- Use this modifier if two surgeons worked together as primary surgeons performing distinct parts of the procedure.
8. Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
- Apply this modifier if the same procedure was repeated by the same physician.
9. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional
- Use this modifier if the same procedure was repeated by a different physician.
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
- Apply this modifier if the patient had to 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
- Use this modifier if an unrelated procedure was performed by the same physician during the postoperative period.
12. Modifier 80 - Assistant Surgeon
- Apply this modifier if an assistant surgeon was necessary for the procedure.
13. Modifier 81 - Minimum Assistant Surgeon
- Use this modifier if a minimum assistant surgeon was required.
14. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Apply this modifier if an assistant surgeon was necessary because a qualified resident surgeon was not available.
15. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Use this modifier if a physician assistant, nurse practitioner, or clinical nurse specialist assisted in the surgery.
These modifiers help provide additional information about the circumstances of the procedure, ensuring accurate billing and reimbursement. Always verify payer-specific guidelines as they may have unique requirements or restrictions regarding the use of these modifiers.
Medicare reimbursement for CPT code 21366, which refers to the open treatment of a complex malar fracture with graft, depends on several factors including the specific Medicare Administrative Contractor (MAC) jurisdiction, the setting in which the procedure is performed, and the patient's individual Medicare plan.
As of the latest available data, Medicare does reimburse for CPT code 21366, but the reimbursement amount can vary. For instance, in a hospital outpatient setting, the reimbursement might be different compared to an inpatient setting or an ambulatory surgical center. Additionally, geographic location can influence the reimbursement rates due to regional cost adjustments.
To obtain the most accurate and up-to-date reimbursement amount for CPT code 21366, healthcare providers should refer to the Medicare Physician Fee Schedule (MPFS) or contact their local MAC. These resources will provide the specific allowable amounts and any pertinent billing guidelines.
For example, as of 2023, the national average reimbursement rate for CPT code 21366 in a hospital outpatient setting might be approximately $1,200, but this figure can vary. Always verify with the latest MPFS data or your MAC for precise figures.
In summary, Medicare does reimburse for CPT code 21366, but the exact amount can vary based on multiple factors. Healthcare providers should consult the MPFS or their local MAC for the most accurate reimbursement information.
Discover how MD Clarity's RevFind software can meticulously read your contracts and detect underpayments down to the CPT code level, including specific codes like 21366 for open treatment of complex malar fractures with grafts. Ensure you're receiving accurate reimbursements from every payer. Schedule a demo today to see RevFind in action and protect your revenue.
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