CPT code 21465 is for treating a lower jaw fracture.
CPT code 21465 is used for the surgical treatment of a lower jaw (mandible) fracture. This procedure involves the realignment and stabilization of the broken bone to ensure proper healing and function.
When billing for CPT code 21465, which pertains to the treatment of a lower jaw fracture, it is important 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 21465, 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 factors such as the complexity of the fracture or patient-specific complications.
2. Modifier 51 (Multiple Procedures):
- Apply this modifier if multiple procedures were performed during the same surgical session. This helps indicate that more than one distinct procedure was carried out.
3. Modifier 52 (Reduced Services):
- Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion. This could occur if the full extent of the procedure was not necessary.
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 clarify that the treatment of the lower jaw fracture was separate from other procedures.
5. Modifier 76 (Repeat Procedure by Same Physician):
- Apply this modifier if the same procedure was repeated by the same physician. This could be relevant if the patient required additional treatment for the same fracture.
6. Modifier 77 (Repeat Procedure by Another Physician):
- Use this modifier if the procedure was repeated by a different physician. This might be necessary if the patient was referred to another specialist for further treatment.
7. 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 had to return to the operating room for a related procedure during the postoperative period. It indicates that the return was unplanned and related to the initial treatment.
8. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period):
- Apply this modifier if an unrelated procedure was performed by the same physician during the postoperative period of the initial surgery. This helps to distinguish the new procedure from the initial treatment.
9. Modifier 80 (Assistant Surgeon):
- Use this modifier if an assistant surgeon was required to help perform the procedure. This indicates that additional surgical assistance was necessary.
10. Modifier 81 (Minimum Assistant Surgeon):
- Apply this modifier if a minimum assistant surgeon was required. This is used when the assistance was less extensive than that indicated by Modifier 80.
11. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available)):
- Use this modifier if an assistant surgeon was necessary because a qualified resident surgeon was not available. This is particularly relevant in teaching hospitals.
12. 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. This indicates the involvement of non-physician practitioners in the procedure.
By appropriately applying these modifiers, healthcare providers can ensure that their billing for CPT code 21465 accurately reflects the services provided and meets payer requirements.
Medicare reimbursement for CPT code 21465, which pertains to the treatment of a lower jaw fracture, depends on several factors including the specific Medicare plan, the setting in which the service is provided, and the geographic location. Generally, Medicare Part B may cover this procedure if it is deemed medically necessary and performed by a qualified healthcare provider.
To determine if CPT code 21465 is reimbursed by Medicare and the specific reimbursement amount, healthcare providers should refer to the Medicare Physician Fee Schedule (MPFS) or use the Medicare Administrative Contractor (MAC) lookup tools. These resources provide detailed information on covered services and the corresponding reimbursement rates, which can vary.
For the most accurate and up-to-date information, providers should consult the MPFS database or contact their local MAC. Additionally, it is advisable to verify coverage and reimbursement specifics through the Medicare Coverage Database (MCD) or by contacting Medicare directly.
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 21465 for treating lower jaw fractures. 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.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
