CPT code 26111 is for excision of a lesion from the hand, subcutaneous tissue, measuring 1.5 cm or less.
CPT code 26113 is used to describe the surgical procedure for the excision (removal) of a deep tumor in the hand that is 1.5 centimeters or larger. This code is specific to procedures where the tumor is located deep within the hand tissues, requiring more intricate surgical techniques to ensure complete removal while preserving hand function.
When billing for CPT code 26113 (Excision of deep tumor of the hand or finger, less than 1.5 cm), it is essential to consider the appropriate use of modifiers to ensure accurate reimbursement and compliance with payer guidelines. Below is a list of potential modifiers that could be used with CPT code 26113, along with the reasons for their use:
1. Modifier 22 - Increased Procedural Services
- Use this modifier if the work required to perform the procedure is substantially greater than typically required. Documentation must support the increased complexity.
2. Modifier 50 - Bilateral Procedure
- Use this modifier if the procedure is performed on both hands or fingers during the same session.
3. Modifier 51 - Multiple Procedures
- Use this modifier when multiple procedures are performed during the same surgical session. This helps indicate that more than one procedure was performed.
4. Modifier 52 - Reduced Services
- Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion.
5. Modifier 59 - Distinct Procedural Service
- Use this modifier to indicate that the procedure is distinct or independent from other services performed on the same day. This is often used to bypass National Correct Coding Initiative (NCCI) edits.
6. Modifier 76 - Repeat Procedure by Same Physician
- Use this modifier if the same procedure is repeated by the same physician on the same day.
7. Modifier 77 - Repeat Procedure by Another Physician
- Use this modifier if the same procedure is 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 requires a 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
- Use this modifier if an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
10. Modifier LT - Left Side
- Use this modifier to specify that the procedure was performed on the left hand or finger.
11. Modifier RT - Right Side
- Use this modifier to specify that the procedure was performed on the right hand or finger.
12. Modifier XS - Separate Structure
- Use this modifier to indicate that a service is distinct because it was performed on a separate organ/structure.
13. Modifier XE - Separate Encounter
- Use this modifier to indicate that a service is distinct because it was performed during a separate encounter.
14. Modifier XP - Separate Practitioner
- Use this modifier to indicate that a service is distinct because it was performed by a different practitioner.
15. Modifier XU - Unusual Non-Overlapping Service
- Use this modifier to indicate that a service is distinct because it does not overlap usual components of the main service.
Proper use of these modifiers can help ensure that claims are processed correctly and that healthcare providers receive appropriate reimbursement for their services. Always refer to the latest coding guidelines and payer-specific requirements when applying modifiers.
CPT code 26113 is reimbursed by Medicare, but the reimbursement is subject to specific conditions outlined in the Medicare Physician Fee Schedule (MPFS). The MPFS provides detailed information on the allowable amount for this procedure, which can vary based on geographic location and other factors. Additionally, Medicare Administrative Contractors (MACs) play a crucial role in determining the reimbursement rates and guidelines for CPT code 26113. It is essential for healthcare providers to consult their respective MACs to understand the specific reimbursement criteria and any local coverage determinations that may apply.
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 26113. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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