CPT code 21931 is a medical billing code for excising a back lesion smaller than 3 cm.
CPT code 21931 is used for the excision of a benign tumor or lesion from the back, specifically when the size of the lesion is 3 centimeters or less. This code indicates that the procedure involves removing the lesion along with some surrounding tissue to ensure complete excision.
For CPT code 21931, which refers to the excision of a back lesion measuring 3 cm or greater, the following modifiers may be applicable:
1. Modifier 22 (Increased Procedural Services): This modifier is used when the work required to perform the procedure is substantially greater than typically required. For example, if the lesion is deeply embedded or if there are complications that require additional time and effort.
2. Modifier 50 (Bilateral Procedure): If the procedure is performed on both sides of the body, this modifier should be used to indicate that the excision was bilateral.
3. Modifier 51 (Multiple Procedures): When multiple procedures are performed during the same surgical session, this modifier is used to indicate that more than one procedure was carried out.
4. Modifier 59 (Distinct Procedural Service): This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. For example, if another unrelated procedure was performed on a different site.
5. Modifier 76 (Repeat Procedure by Same Physician): If the same procedure 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 procedure is repeated by a different physician on the same day, this modifier should be applied.
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): This modifier is used 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): This modifier is used when an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
9. Modifier 80 (Assistant Surgeon): If an assistant surgeon is required for the procedure, this modifier should be used.
10. Modifier 81 (Minimum Assistant Surgeon): This modifier is used when a minimum assistant surgeon is required for the procedure.
11. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available)): This modifier is used when an assistant surgeon is necessary because a qualified resident surgeon is not available.
12. Modifier AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery): This modifier is used when a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery.
Each of these modifiers serves a specific purpose and should be used appropriately to ensure accurate billing and reimbursement for the services provided.
When determining if a specific CPT code, such as 21931 (Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater), is reimbursed by Medicare, it is essential to consult the Medicare Physician Fee Schedule (MPFS) and Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs).
For CPT code 21931, Medicare does provide reimbursement, but the amount can vary based on several factors, including geographic location, the setting in which the service is provided (e.g., hospital outpatient department vs. physician's office), and any applicable modifiers.
As of the latest available data, the national average reimbursement rate for CPT code 21931 is approximately $400. However, this amount is subject to change and may differ based on the aforementioned factors. Providers should verify the exact reimbursement rate through the MPFS Look-Up Tool on the CMS website or consult their Medicare Administrative Contractor (MAC) for the most accurate and up-to-date information.
Additionally, it is crucial to ensure that the procedure meets all Medicare coverage criteria and documentation requirements to avoid claim denials or delays in payment.
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 21931. Ensure you receive every dollar you're owed from each 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
