CPT code 26115 is for excision of a lesion on the hand, less than 1.5 cm.
CPT code 26116 is used to describe the surgical procedure for the excision of a deep tumor in the hand that is less than 1.5 centimeters in size. This code is specific to operations where the tumor is located beneath the surface tissues, requiring more intricate surgical techniques to remove it completely.
When billing for CPT code 26116 (Excision of tumor or vascular malformation, soft tissue of hand or finger, subfascial (e.g., intramuscular); less than 1.5 cm), the following modifiers may be applicable:
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 substantial additional work and the reason for it.
2. Modifier 50 - Bilateral Procedure: If the procedure is performed on both hands or fingers during the same operative session, this modifier should be used.
3. Modifier 51 - Multiple Procedures: If multiple procedures are performed during the same surgical session, this modifier indicates that multiple services were provided.
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: This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day.
6. Modifier 76 - Repeat Procedure by Same Physician: If the same procedure is repeated by the same physician, this modifier should be used.
7. Modifier 77 - Repeat Procedure by Another Physician: If the same procedure is repeated by a different physician, this modifier should be used.
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: This modifier is used if the patient needs to 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.
10. Modifier LT - Left Side: This modifier is used to specify that the procedure was performed on the left hand or finger.
11. Modifier RT - Right Side: This modifier is used to specify that the procedure was performed on the right hand or finger.
12. Modifier XS - Separate Structure: This modifier indicates that a service was performed on a separate organ/structure.
13. Modifier XE - Separate Encounter: This modifier is used to indicate that a service was performed during a separate encounter.
14. Modifier XP - Separate Practitioner: This modifier is used when a service is performed by a different practitioner.
15. Modifier XU - Unusual Non-Overlapping Service: This modifier is used to indicate that the service does not overlap usual components of the main service.
These modifiers help provide additional information about the procedure performed and ensure accurate billing and reimbursement. Always ensure that the use of modifiers is supported by proper documentation in the patient's medical record.
CPT code 26116 is reimbursed by Medicare, but the reimbursement is subject to specific conditions outlined in the Medicare Physician Fee Schedule (MPFS). The MPFS provides a comprehensive list of services covered by Medicare and the corresponding payment rates. To determine the exact reimbursement rate and any additional requirements, healthcare providers should consult the MPFS.
Additionally, Medicare Administrative Contractors (MACs) play a crucial role in processing claims and providing guidance on Medicare coverage. Each MAC may have specific local coverage determinations (LCDs) that can affect the reimbursement of CPT code 26116. Therefore, it is advisable for healthcare providers to check with their respective MAC to ensure compliance with any local policies and to obtain accurate reimbursement information.
Discover how MD Clarity's RevFind software can meticulously analyze your contracts and pinpoint underpayments, even down to specific CPT codes like 26116 and by individual payer. Ensure you're receiving the full reimbursement you deserve. Schedule a demo today to see RevFind in action.
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