CPT code 21920 is a medical code used to describe a biopsy procedure of the soft tissue in the back for billing and documentation purposes.
CPT code 21920 is used for a medical procedure that involves taking a small sample of soft tissue from the back for examination. This biopsy helps in diagnosing various conditions by analyzing the tissue under a microscope.
For CPT code 21920 (Biopsy, soft tissue of back), the following modifiers may be applicable:
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 patient condition or complexity of the biopsy.
2. Modifier 50 - Bilateral Procedure: If the biopsy is performed on both sides of the back, this modifier should be used to indicate that the procedure was bilateral.
3. Modifier 51 - Multiple Procedures: If multiple procedures were performed during the same surgical session, this modifier should be used to indicate that more than one procedure was performed.
4. Modifier 59 - Distinct Procedural Service: Use this modifier to indicate that the biopsy was distinct or independent from other services performed on the same day. This is particularly important if the biopsy was performed in a different anatomical site or through a separate incision.
5. Modifier 76 - Repeat Procedure by Same Physician: If the biopsy needs to be repeated by the same physician on the same day, this modifier should be used.
6. Modifier 77 - Repeat Procedure by Another Physician: If the biopsy is repeated by a different physician on the same day, this modifier should be used.
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: Use this modifier if the patient needs to return to the operating room for a related procedure during the postoperative period.
8. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: If the biopsy is performed during the postoperative period of another procedure but is unrelated to the initial procedure, this modifier should be used.
9. Modifier 80 - Assistant Surgeon: If an assistant surgeon is required for the biopsy, this modifier should be used to indicate their involvement.
10. Modifier 81 - Minimum Assistant Surgeon: Use this modifier if a minimum assistant surgeon is required for the procedure.
11. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): If an assistant surgeon is required because a qualified resident surgeon is not available, this modifier should be used.
12. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: Use this modifier if a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery.
These modifiers help provide additional information about the circumstances under which the biopsy was performed, ensuring accurate billing and reimbursement.
When determining if a specific CPT code, such as 21920 (Biopsy, soft tissue of back), is reimbursed by Medicare, it is essential to consult the Medicare Physician Fee Schedule (MPFS) and Local Coverage Determinations (LCDs) for the most accurate and up-to-date information.
As of the latest available data, CPT code 21920 is generally reimbursed by Medicare, provided that the procedure is deemed medically necessary and is performed in accordance with Medicare guidelines. The reimbursement amount can vary based on geographic location, the setting in which the procedure is performed (e.g., hospital outpatient department vs. physician's office), and other factors such as the provider's participation status with Medicare.
To find the specific reimbursement amount for CPT code 21920, healthcare providers should refer to the MPFS Look-Up Tool available on the Centers for Medicare & Medicaid Services (CMS) website. This tool allows providers to input the CPT code and their specific locality to obtain the exact reimbursement rate.
For example, as of the most recent update, the national average reimbursement rate for CPT code 21920 might be approximately $200-$300. However, this is a general estimate, and the actual amount can differ.
Providers should also review any relevant LCDs or National Coverage Determinations (NCDs) to ensure compliance with Medicare's coverage criteria for this procedure. It is advisable to regularly check for updates to Medicare policies and reimbursement rates to ensure accurate billing and optimal revenue cycle management.
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 21920 for biopsy of soft tissue of the back. 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
