CPT code 21935 is a medical code used to describe the surgical removal of a tumor less than 5 cm from the back.
CPT code 21935 is used for the surgical procedure of removing a tumor from the back that is less than 5 centimeters in size.
For CPT code 21935 (Resection of back tumor, less than 5 cm), 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. This could apply if the tumor resection is more complex than usual.
2. Modifier 50 - Bilateral Procedure: Used if the procedure is performed on both sides of the body. This would be rare for a back tumor but could be applicable in specific cases.
3. Modifier 51 - Multiple Procedures: Used when multiple procedures are performed during the same surgical session. This might be relevant if other procedures are performed in addition to the tumor resection.
4. 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 could be necessary if the tumor resection is performed in conjunction with other procedures that are not typically performed together.
5. Modifier 62 - Two Surgeons: Used when two surgeons work together as primary surgeons performing distinct parts of a single reportable procedure. This might be applicable if the tumor resection requires the expertise of two surgeons.
6. Modifier 66 - Surgical Team: Used when a team of surgeons is required to perform the procedure. This could be relevant for particularly complex tumor resections.
7. Modifier 76 - Repeat Procedure by Same Physician: Used if the same physician needs to repeat the procedure. This could apply if a second resection is necessary due to incomplete removal of the tumor.
8. Modifier 77 - Repeat Procedure by Another Physician: Used if a different physician needs to repeat the procedure. This might be relevant if the initial resection was incomplete and another surgeon performs the follow-up procedure.
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 if the patient needs to 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 if an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
11. Modifier 80 - Assistant Surgeon: Used when an assistant surgeon is required for the procedure.
12. Modifier 81 - Minimum Assistant Surgeon: Used when a minimum assistant surgeon is required for 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 these healthcare professionals assist in the surgery.
Each of these modifiers serves a specific purpose and should be used according to the guidelines and documentation requirements to ensure accurate billing and reimbursement.
When determining if a specific CPT code, such as 21935 (Resect back tum < 5 cm), is reimbursed by Medicare, it is essential to consult the Medicare Physician Fee Schedule (MPFS) and the National Correct Coding Initiative (NCCI) edits.
For CPT code 21935, Medicare does provide reimbursement, but the exact amount can vary based on several factors, including geographic location, the setting in which the procedure is performed, and any applicable modifiers. As of the latest MPFS update, the national average reimbursement for CPT code 21935 is approximately $500. However, this amount can fluctuate, so it is crucial to verify the current rate through the MPFS Look-Up Tool or your local Medicare Administrative Contractor (MAC).
Additionally, ensure that all documentation and coding guidelines are meticulously followed to avoid claim denials or delays. Proper coding and adherence to Medicare's billing requirements are essential for successful reimbursement.
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 21935 for resecting back tumors under 5 cm. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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