CPT code 21395 is for open treatment of orbit and periorbital area with graft.
CPT code 21395 is for the open treatment of an orbital or periorbital fracture, which involves the use of a graft. This procedure is typically performed to repair and stabilize fractures around the eye socket, ensuring proper healing and function.
For CPT code 21395 (Open treatment of orbit, including internal and external fixation and/or grafting, with or without implant), the following modifiers may be applicable:
1. Modifier 22 - Increased Procedural Services
- Use this modifier if the work required to perform the procedure is substantially greater than typically required. Documentation must support the substantial additional work and the reason for it.
2. Modifier 51 - Multiple Procedures
- Apply this modifier when multiple procedures are performed during the same surgical session. This indicates that more than one procedure was carried out.
3. 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), more extensive than the original procedure, or for therapy following a surgical procedure.
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. It helps to identify procedures that are not typically reported together but are appropriate under the circumstances.
5. 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 or other qualified healthcare professional subsequent to the original procedure.
6. 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 when a patient requires a return to the operating room for a related procedure during the postoperative period of the initial surgery.
7. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- Apply this modifier if an unrelated procedure or service is performed by the same physician during the postoperative period of the initial procedure.
8. Modifier 80 - Assistant Surgeon
- Use this modifier when an assistant surgeon is required to assist with the procedure.
9. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- This modifier is used when an assistant surgeon is necessary, and a qualified resident surgeon is not available.
10. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Apply this modifier when a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery.
Each of these modifiers serves a specific purpose and should be used in accordance with the guidelines to ensure accurate billing and reimbursement. Proper documentation is essential to support the use of any modifier.
When considering whether Medicare reimburses for a specific CPT code, such as 21395 (Open treatment of orbit, periorbital area with graft), it is essential to consult the Medicare Physician Fee Schedule (MPFS) and Local Coverage Determinations (LCDs) for the most accurate and up-to-date information.
As of the latest available data, CPT code 21395 is generally reimbursed by Medicare, provided that the procedure is deemed medically necessary and is performed in accordance with Medicare guidelines. The reimbursement amount can vary based on several factors, including geographic location, the setting in which the procedure is performed (e.g., hospital outpatient department vs. physician's office), and any applicable modifiers.
For a precise reimbursement amount, healthcare providers should refer to the MPFS or use the Medicare Fee Schedule Lookup Tool available on the Centers for Medicare & Medicaid Services (CMS) website. Additionally, consulting with your Medicare Administrative Contractor (MAC) can provide specific details tailored to your region and practice.
In summary, CPT code 21395 is reimbursed by Medicare, but the exact reimbursement amount will depend on various factors and should be verified through official Medicare resources.
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 21395 for open treatment of orbit and periorbita with graft. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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