CPT code 23615 is for the open treatment of a proximal humeral fracture with internal fixation.
CPT code 23615 is used to describe the surgical procedure for the open treatment of a proximal humeral fracture, which involves internal fixation. This means that a surgeon makes an incision to access the broken upper part of the humerus (the bone of the upper arm) and uses hardware such as plates, screws, or rods to stabilize and fix the fracture. This code is essential for accurately documenting and billing for this specific type of orthopedic surgery.
When billing for CPT code 23615 (Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed), 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. Documentation must support the substantial additional work and the reason for it.
2. Modifier 51 - Multiple Procedures: Apply this modifier if multiple procedures were performed during the same surgical session. This helps indicate that more than one procedure was carried out.
3. Modifier 52 - Reduced Services: Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion. Documentation should support the reason for the reduction.
4. Modifier 53 - Discontinued Procedure: This modifier is used if the procedure was started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
5. Modifier 54 - Surgical Care Only: Apply this modifier if the provider is only performing the surgical portion of the procedure and not providing pre- or post-operative care.
6. Modifier 55 - Postoperative Management Only: Use this modifier if the provider is only responsible for the postoperative care of the patient.
7. Modifier 56 - Preoperative Management Only: This modifier is used if the provider is only responsible for the preoperative care of the patient.
8. Modifier 62 - Two Surgeons: Use this modifier if two surgeons are required to perform the procedure due to its complexity. Both surgeons must document their specific roles in the surgery.
9. Modifier 66 - Surgical Team: Apply this modifier if the procedure requires a surgical team due to its complexity. Documentation should support the necessity of a team approach.
10. Modifier 76 - Repeat Procedure by Same Physician: Use this modifier if the same physician needs to repeat the procedure on the same day.
11. Modifier 77 - Repeat Procedure by Another Physician: This modifier is used if a different physician needs to repeat the procedure on the same day.
12. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: Apply this modifier if the patient needs to return to the operating room for a related procedure during the postoperative period.
13. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Use this modifier if an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
14. Modifier 80 - Assistant Surgeon: This modifier is used if an assistant surgeon is required for the procedure.
15. Modifier 81 - Minimum Assistant Surgeon: Apply this modifier if a minimum assistant surgeon is required for the procedure.
16. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Use this modifier if an assistant surgeon is required because a qualified resident surgeon is not available.
17. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: This modifier is used when a PA, NP, or CNS assists in the surgery.
Each modifier serves a specific purpose and should be used in accordance with the documentation and circumstances surrounding the procedure. Proper use of modifiers ensures accurate billing and reimbursement.
Determining whether CPT code 23615 is reimbursed by Medicare involves consulting the Medicare Physician Fee Schedule (MPFS) and the guidelines set forth by the Medicare Administrative Contractor (MAC) for your specific region. The MPFS provides a comprehensive list of services and their corresponding reimbursement rates under Medicare Part B.
To ascertain if CPT code 23615 is reimbursed, you would first need to check the MPFS. This can be done through the Centers for Medicare & Medicaid Services (CMS) website, where you can search for the specific CPT code and review its status and reimbursement rate.
Additionally, it is crucial to consult the local MAC, as they are responsible for processing Medicare claims and can provide region-specific information regarding coverage and reimbursement policies. Each MAC may have unique guidelines or requirements that could affect whether CPT code 23615 is reimbursed in your area.
In summary, to determine if CPT code 23615 is reimbursed by Medicare, you must review the MPFS and consult your local MAC for any additional regional guidelines or stipulations.
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