CPT CODES

CPT Code 21820

CPT code 21820 is for treating a sternum fracture, detailing the specific medical procedure for accurate billing and documentation.

Table of Contents
What is CPT Code 21820
Does CPT 21820 Need a Modifier?
CPT Code 21820 Medicare Reimbursement
Are You Being Underpaid for 21820 CPT Code?
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What is CPT Code 21820

CPT code 21820 is used for the treatment of a sternum fracture. This code specifically refers to the medical procedure where a healthcare provider addresses and manages a broken sternum, which is the bone located in the center of the chest.

Does CPT 21820 Need a Modifier?

When billing for CPT code 21820 (Treat sternum fracture), it is essential to consider the appropriate modifiers to ensure accurate reimbursement and compliance with payer requirements. Below is a list of potential modifiers that could be used with CPT code 21820, 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 complications or unusual circumstances.

2. Modifier 24 - Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period
- Apply this modifier if an unrelated E/M service is performed by the same physician during the postoperative period of the initial procedure.

3. Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
- Use this modifier when a significant, separately identifiable E/M service is provided by the same physician on the same day as the procedure.

4. Modifier 50 - Bilateral Procedure
- This modifier is used if the procedure is performed bilaterally. However, it is unlikely to be applicable for a sternum fracture treatment, but it is included for completeness.

5. Modifier 51 - Multiple Procedures
- Apply this modifier if multiple procedures are performed during the same surgical session. This helps indicate that more than one procedure was carried out.

6. Modifier 52 - Reduced Services
- Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion.

7. Modifier 53 - Discontinued Procedure
- This modifier is used if the procedure was started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.

8. Modifier 59 - Distinct Procedural Service
- Apply this modifier to indicate that a procedure or service was distinct or independent from other services performed on the same day.

9. 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.

10. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional
- Apply this modifier if the procedure is repeated by a different physician.

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
- Use this modifier if an assistant surgeon is required during the procedure.

14. Modifier 81 - Minimum Assistant Surgeon
- Apply this modifier if a minimum assistant surgeon is required.

15. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Use this modifier if an assistant surgeon is required because a qualified resident surgeon is not available.

16. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Apply this modifier if a PA, NP, or CNS assists in the surgery.

Each modifier serves a specific purpose and should be used accurately to reflect the services provided and ensure proper reimbursement. Always verify payer-specific guidelines as they may have unique requirements or restrictions regarding the use of modifiers.

CPT Code 21820 Medicare Reimbursement

Medicare reimbursement for CPT code 21820, which pertains to the treatment of a sternum fracture, depends on several factors including the setting in which the service is provided (e.g., inpatient, outpatient, or physician's office) and the specific Medicare Administrative Contractor (MAC) jurisdiction. Generally, Medicare does cover medically necessary procedures, including the treatment of sternum fractures.

To determine the exact reimbursement amount for CPT code 21820, you would need to consult the Medicare Physician Fee Schedule (MPFS) or the relevant MAC's fee schedule. As of the latest updates, the national average reimbursement for CPT code 21820 can vary, but it typically falls within a specific range. For precise figures, healthcare providers should refer to the current year's MPFS or contact their MAC directly.

It's also important to note that the reimbursement amount may be subject to adjustments based on geographic location, the complexity of the case, and other factors such as the use of modifiers. Therefore, for the most accurate and up-to-date information, always refer to the official Medicare resources or your MAC.

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