CPT code 21811 is for the surgical repair of rib fractures using a scope.
CPT code 21811 is for the surgical procedure of fixing a rib fracture using a minimally invasive technique called thoracoscopy. This involves making small incisions and using a scope to guide the repair, which typically results in less pain and quicker recovery compared to traditional open surgery.
When billing for CPT code 21811 (Open treatment of rib fracture(s) with internal fixation, includes thoracoscopy when performed), the following modifiers may be applicable depending on the specific circumstances of the procedure:
1. Modifier 22 (Increased Procedural Services): Used when the work required to provide a service is substantially greater than typically required. Documentation must support the substantial additional work and the reason for it.
2. Modifier 50 (Bilateral Procedure): Used if the procedure is performed on both sides of the body. This modifier indicates that the same procedure was performed on a mirror-image anatomical site.
3. Modifier 51 (Multiple Procedures): Used when multiple procedures are performed during the same surgical session. This modifier helps indicate that more than one procedure was performed.
4. Modifier 52 (Reduced Services): Used when a service or procedure is partially reduced or eliminated at the physician's discretion. This modifier indicates that the service provided was less than usually required.
5. Modifier 59 (Distinct Procedural Service): Used to indicate that a procedure or service was distinct or independent from other services performed on the same day. This modifier is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances.
6. Modifier 62 (Two Surgeons): Used when two surgeons work together as primary surgeons performing distinct parts of a procedure. Each surgeon should report their distinct operative work.
7. Modifier 76 (Repeat Procedure by Same Physician): Used to indicate that a procedure or service was repeated by the same physician subsequent to the original procedure or service.
8. Modifier 77 (Repeat Procedure by Another Physician): Used to indicate that a procedure or service was repeated by another physician subsequent to the original procedure or service.
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): Used when a patient requires a return to the operating room for a related procedure during the postoperative period.
10. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): Used when a procedure or service performed during the postoperative period is unrelated to the original procedure.
11. Modifier 80 (Assistant Surgeon): Used when an assistant surgeon is required during the procedure. This modifier indicates that another surgeon assisted in the procedure.
12. Modifier 81 (Minimum Assistant Surgeon): Used when an assistant surgeon provides minimal assistance during the procedure.
13. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available)): Used when an assistant surgeon is required, and a qualified resident surgeon is not available.
14. Modifier AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery): Used when a non-physician practitioner assists in the surgery.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement. Always ensure that the use of modifiers is supported by appropriate documentation in the patient's medical record.
Determining whether a specific CPT code, such as 21811 (Optx of rib fx w/fixj scope), is reimbursed by Medicare involves several steps. Medicare reimbursement is contingent on various factors including medical necessity, the setting in which the service is provided, and whether the service is covered under Medicare's guidelines.
For CPT code 21811, Medicare does provide reimbursement, but the amount can vary based on geographic location, the specific Medicare Administrative Contractor (MAC), and the facility where the procedure is performed (e.g., hospital outpatient department, ambulatory surgical center).
To find the exact reimbursement amount, healthcare providers should refer to the Medicare Physician Fee Schedule (MPFS) or the Ambulatory Surgical Center (ASC) Payment Rates. These resources are updated annually and provide detailed information on the allowable amounts for each CPT code.
For example, as of the latest update, the national average reimbursement for CPT code 21811 under the MPFS might be approximately $1,500. However, this figure can fluctuate based on the aforementioned factors. Providers are encouraged to use the Medicare Fee Schedule Lookup Tool available on the Centers for Medicare & Medicaid Services (CMS) website to obtain the most accurate and current reimbursement rates.
In summary, CPT code 21811 is reimbursed by Medicare, but the exact amount will depend on several variables. Always consult the latest Medicare resources or your local MAC for precise information.
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 21811 for rib fracture fixation with scope. Ensure you're receiving accurate reimbursements from every payer. Schedule a demo today to see how RevFind can enhance your revenue cycle management.
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