CPT code 23605 is for the closed treatment of a proximal humeral fracture with manipulation, with or without traction.
CPT code 23605 is used to describe the closed treatment of a proximal humeral (upper arm bone) fracture, including the manipulation of the bone to ensure proper alignment. This code is typically used when the procedure is performed without the need for surgical incision, often involving techniques such as traction or manual adjustment to reposition the fractured bone.
When billing for CPT code 23605 (Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation), 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 23605, along with the reasons for their use:
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 fracture treatment was unusually complex.
2. Modifier 24 (Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period): Used if an unrelated E/M service is performed during the postoperative period of the fracture treatment.
3. Modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service): Used if a significant, separately identifiable E/M service is provided on the same day as the fracture treatment.
4. Modifier 50 (Bilateral Procedure): Used if the procedure is performed on both shoulders during the same session.
5. Modifier 51 (Multiple Procedures): Used if multiple procedures are performed during the same surgical session.
6. Modifier 52 (Reduced Services): Used if the procedure is partially reduced or eliminated at the physician's discretion.
7. Modifier 53 (Discontinued Procedure): Used if the procedure is discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
8. Modifier 54 (Surgical Care Only): Used if the physician provides only the surgical care portion of the treatment.
9. Modifier 55 (Postoperative Management Only): Used if the physician provides only the postoperative management portion of the treatment.
10. Modifier 56 (Preoperative Management Only): Used if the physician provides only the preoperative management portion of the treatment.
11. Modifier 57 (Decision for Surgery): Used if the E/M service resulted in the decision to perform the surgery.
12. Modifier 58 (Staged or Related Procedure or Service by the Same Physician During the Postoperative Period): Used if a subsequent procedure is planned or staged during the postoperative period of the initial procedure.
13. Modifier 59 (Distinct Procedural Service): Used if a procedure or service is distinct or independent from other services performed on the same day.
14. Modifier 76 (Repeat Procedure or Service by Same Physician): Used if the same procedure is repeated by the same physician.
15. Modifier 77 (Repeat Procedure by Another Physician): Used if the same procedure is repeated by a different physician.
16. 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 requires an unplanned return to the operating room for a related procedure during the postoperative period.
17. 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.
18. Modifier 80 (Assistant Surgeon): Used if an assistant surgeon is required during the procedure.
19. Modifier 81 (Minimum Assistant Surgeon): Used if a minimum assistant surgeon is required during the procedure.
20. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available)): Used if an assistant surgeon is required and a qualified resident surgeon is not available.
21. Modifier 99 (Multiple Modifiers): Used if multiple modifiers are necessary to describe the service provided.
Proper use of these modifiers can help ensure that claims are processed correctly and that healthcare providers receive appropriate reimbursement for the services rendered. Always refer to the latest coding guidelines and payer-specific requirements when applying modifiers.
The CPT code 23605 is reimbursed by Medicare, but the reimbursement is subject to specific conditions and guidelines outlined in the Medicare Physician Fee Schedule (MPFS). The MPFS provides a comprehensive list of services and procedures covered by Medicare, along with the corresponding reimbursement rates.
To determine the exact reimbursement for CPT code 23605, healthcare providers should refer to the MPFS, which is updated annually. Additionally, Medicare Administrative Contractors (MACs) play a crucial role in processing claims and providing guidance on coverage policies. Each MAC may have localized policies and guidelines that can affect the reimbursement process for CPT code 23605. Therefore, it is advisable for healthcare providers to consult their respective MAC for detailed information on coverage and reimbursement for this specific code.
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