CPT code 21742 is for the repair of the sternum using the Nuss procedure without the use of a scope.
CPT code 21742 is for the surgical repair of the sternum using the Nuss procedure without the use of a scope. This code is used when a surgeon corrects a chest wall deformity, such as pectus excavatum, by inserting a curved metal bar under the sternum to elevate it, but does not use a thoracoscope (a type of endoscope) during the procedure.
When billing for CPT code 21742 (Repair of pectus excavatum or carinatum; minimally invasive (Nuss procedure), without thoracoscopy), 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 21742, 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. Documentation must support the increased complexity or time.
2. Modifier 50 (Bilateral Procedure): If the procedure is performed bilaterally, this modifier indicates that the same 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. It helps to indicate that more than one procedure was carried out.
4. Modifier 52 (Reduced Services): If the procedure was partially reduced or eliminated at the physician's discretion, this modifier should be used to indicate that the service provided was less than usually required.
5. Modifier 53 (Discontinued Procedure): Apply this modifier if the procedure was started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
6. Modifier 59 (Distinct Procedural Service): Use this modifier to indicate that the procedure was distinct or independent from other services performed on the same day. This is particularly important if there is a risk of bundling with other procedures.
7. Modifier 62 (Two Surgeons): If two surgeons are required to perform the procedure together, this modifier indicates that each surgeon performed a distinct part of the procedure.
8. Modifier 66 (Surgical Team): Use this modifier when the procedure requires a surgical team due to its complexity.
9. Modifier 76 (Repeat Procedure by Same Physician): If the same physician repeats the procedure on the same day, this modifier should be used to indicate the repetition.
10. Modifier 77 (Repeat Procedure by Another Physician): If another physician repeats the procedure on the same day, this modifier should be used.
11. 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 needs to return to the operating room for a related procedure during the postoperative period.
12. 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.
13. Modifier 80 (Assistant Surgeon): If an assistant surgeon is required for the procedure, this modifier should be used to indicate their involvement.
14. Modifier 81 (Minimum Assistant Surgeon): Use this modifier if a minimum assistant surgeon is required.
15. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available)): Apply this modifier if an assistant surgeon is necessary due to the unavailability of a qualified resident surgeon.
16. Modifier AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery): Use this modifier when a non-physician provider assists in the surgery.
Proper use of these modifiers ensures that the billing accurately reflects the services provided, which is crucial for appropriate reimbursement and compliance with payer policies. Always refer to the latest coding guidelines and payer-specific requirements when applying modifiers.
Medicare reimbursement for CPT code 21742, which pertains to the repair of the sternum using the Nuss procedure without the use of a scope, depends on several factors including the specific Medicare Administrative Contractor (MAC) jurisdiction, the setting in which the procedure is performed (e.g., inpatient vs. outpatient), and the patient's specific Medicare plan.
As of the latest available data, Medicare does reimburse for CPT code 21742, but the reimbursement amount can vary. For instance, in an outpatient setting, the reimbursement might be different compared to an inpatient setting due to the differing payment systems (Outpatient Prospective Payment System (OPPS) vs. Inpatient Prospective Payment System (IPPS)).
To get the most accurate and up-to-date reimbursement amount, healthcare providers should refer to the Medicare Physician Fee Schedule (MPFS) or contact their local MAC. Additionally, tools like the Medicare Fee Schedule Lookup Tool can provide specific reimbursement rates based on geographic location and other factors.
For example, as of the latest MPFS update, the national average reimbursement for CPT code 21742 might be approximately $1,500, but this is subject to change and should be verified through official Medicare resources or your MAC.
In summary, while Medicare does reimburse for CPT code 21742, the exact amount can vary, and providers should consult the latest Medicare resources or their MAC for precise information.
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 21742 for stern/nuss repair without scope. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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