CPT code 21825 is a medical code used to describe the treatment of a sternum fracture.
CPT code 21825 is used for the surgical treatment of a fractured sternum. This code indicates that a healthcare provider has performed a procedure to repair or stabilize a broken sternum, which is the bone located in the center of the chest. This treatment is necessary to ensure proper healing and to restore the normal function of the chest area.
When billing for CPT code 21825 (Treat sternum fracture), 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 21825, 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 other factors that increased the complexity of the treatment.
2. Modifier 51 (Multiple Procedures):
- Apply this modifier when multiple procedures are performed during the same surgical session. It indicates that more than one procedure was carried out, which may affect reimbursement.
3. 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 are other procedures that might be bundled together.
4. Modifier 76 (Repeat Procedure by Same Physician):
- This modifier is used if the same procedure (21825) is repeated by the same physician on the same day. It helps to clarify that the repeat procedure was necessary.
5. Modifier 77 (Repeat Procedure by Another Physician):
- Apply this modifier if the procedure is repeated by a different physician on the same day. It indicates that the repeat procedure was performed by another provider.
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):
- Use this modifier if the patient needs to return to the operating room for a related procedure during the postoperative period. It signifies that the return was unplanned and related to the initial procedure.
7. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period):
- This modifier is used when an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure. It indicates that the new procedure is not related to the initial surgery.
8. Modifier 80 (Assistant Surgeon):
- Apply this modifier if an assistant surgeon was necessary for the procedure. It indicates that another surgeon assisted in the treatment.
9. Modifier 81 (Minimum Assistant Surgeon):
- Use this modifier if a minimum assistant surgeon was required. It signifies that the assistance was minimal but necessary.
10. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available)):
- This modifier is used when an assistant surgeon is required because a qualified resident surgeon was not available.
11. 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.
By appropriately using these modifiers, healthcare providers can ensure that their billing for CPT code 21825 is accurate and reflective of the services provided, thereby optimizing reimbursement and maintaining compliance with payer guidelines.
When it comes to determining if a specific CPT code, such as 21825 (Treat sternum fracture), is reimbursed by Medicare, several factors need to be considered. Medicare reimbursement policies are guided by the Medicare Physician Fee Schedule (MPFS), which outlines the payment rates for services provided to Medicare beneficiaries.
For CPT code 21825, Medicare does provide reimbursement, but the exact amount can vary based on geographic location, the setting in which the service is provided (e.g., hospital outpatient department, physician's office), and other factors such as the provider's participation status with Medicare.
As of the latest available data, the national average reimbursement rate for CPT code 21825 is approximately $1,200. However, this figure is subject to change and should be verified through the MPFS or by consulting with your Medicare Administrative Contractor (MAC) for the most accurate and up-to-date information.
It's also important to note that Medicare may have specific documentation and medical necessity requirements that must be met for the service to be reimbursed. Providers should ensure that all relevant clinical information is thoroughly documented to support the claim.
For the most precise and current reimbursement information, healthcare providers should refer to the Medicare Physician Fee Schedule Look-Up Tool available on the Centers for Medicare & Medicaid Services (CMS) website or contact their local MAC.
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 21825 for treating sternum fractures. Schedule a demo today to see how RevFind can help you identify and recover lost revenue from individual payers.
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