CPT code 23065 is a medical code used to describe the procedure of performing a biopsy on shoulder tissues.
CPT code 23065 is used to describe a medical procedure where a biopsy is taken from the tissues of the shoulder. This involves the removal of a small sample of tissue from the shoulder area for examination, typically to diagnose conditions such as infections, inflammatory diseases, or cancer. The procedure is usually performed by a surgeon or a specialist and may involve the use of imaging guidance to ensure accurate sampling.
When billing for CPT code 23065 (Biopsy, shoulder tissues), 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 23065, 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. Documentation must support the increased complexity.
2. Modifier 50 - Bilateral Procedure
- Apply this modifier if the biopsy was performed on both shoulders during the same session.
3. Modifier 51 - Multiple Procedures
- Use this modifier when multiple procedures, other than E/M services, are performed by the same provider during the same session.
4. Modifier 52 - Reduced Services
- This modifier is used when the procedure is partially reduced or eliminated at the physician's discretion.
5. Modifier 59 - Distinct Procedural Service
- Apply this modifier to indicate that the biopsy was a distinct procedural service from other services performed on the same day.
6. Modifier 76 - Repeat Procedure by Same Physician
- Use this modifier if the same procedure was repeated by the same physician on the same day.
7. Modifier 77 - Repeat Procedure by Another Physician
- Apply this modifier if the same procedure was repeated by a different physician on the same day.
8. 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 required an unplanned return to the operating room for a related procedure during the postoperative period.
9. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- Apply this modifier if the biopsy was performed during the postoperative period of another, unrelated procedure.
10. Modifier LT - Left Side
- Use this modifier to specify that the biopsy was performed on the left shoulder.
11. Modifier RT - Right Side
- Apply this modifier to specify that the biopsy was performed on the right shoulder.
12. Modifier GA - Waiver of Liability Statement Issued as Required by Payer Policy
- Use this modifier if an Advance Beneficiary Notice (ABN) was issued for a service that may not be covered by Medicare.
13. Modifier GC - This Service Has Been Performed in Part by a Resident Under the Direction of a Teaching Physician
- Apply this modifier if the service was performed by a resident under the supervision of a teaching physician.
14. Modifier QX - CRNA Service: With Medical Direction by a Physician
- Use this modifier if the biopsy was performed with the assistance of a Certified Registered Nurse Anesthetist (CRNA) under the medical direction of a physician.
15. Modifier QY - Medical Direction of One CRNA by an Anesthesiologist
- Apply this modifier if an anesthesiologist provided medical direction for one CRNA during the procedure.
16. Modifier QK - Medical Direction of Two, Three, or Four Concurrent Anesthesia Procedures Involving Qualified Individuals
- Use this modifier if the anesthesiologist directed multiple concurrent anesthesia procedures.
Proper use of these modifiers ensures accurate billing and helps avoid claim denials or delays. Always refer to the latest coding guidelines and payer-specific requirements when applying modifiers.
The CPT code 23065 is reimbursed by Medicare, but it is essential to verify its specific reimbursement rate and coverage criteria through the Medicare Physician Fee Schedule (MPFS). The MPFS provides detailed information on the payment rates for services covered under Medicare Part B. Additionally, it is crucial to consult with your regional Medicare Administrative Contractor (MAC) to ensure compliance with local coverage determinations and any specific documentation requirements that may affect reimbursement for CPT code 23065.
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