CPT code 42104 is for the excision of a lesion located on the roof of the mouth, used for billing and documentation in healthcare.
CPT code 42104 is used to describe the surgical procedure of excising a lesion located on the roof of the mouth. This code specifically indicates that the lesion is being removed, which may be necessary for diagnostic purposes or to treat conditions such as oral cancer or other abnormalities. The procedure typically involves cutting away the affected tissue to ensure complete removal and may require subsequent healing and follow-up care.
For CPT code 42104, which pertains to the excision of a lesion from the roof of the mouth, 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. This could be due to factors such as the size, location, or complexity of the lesion.
2. Modifier 50 - Bilateral Procedure: If the excision was performed on both sides of the roof of the mouth, this modifier should be appended.
3. Modifier 51 - Multiple Procedures: If multiple procedures were performed during the same surgical session, this modifier should be used to indicate that.
4. Modifier 52 - Reduced Services: If the procedure was partially reduced or eliminated at the physician's discretion, this modifier should be used.
5. Modifier 59 - Distinct Procedural Service: Use this modifier to indicate that the excision was distinct or independent from other services performed on the same day.
6. Modifier 76 - Repeat Procedure by Same Physician: If the same physician performed the excision more than once on the same day, this modifier should be used.
7. Modifier 77 - Repeat Procedure by Another Physician: If a different physician performed the excision more than once on the same day, 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: Use this modifier if the patient had 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: If an unrelated procedure was performed by the same physician during the postoperative period, this modifier should be used.
10. Modifier 80 - Assistant Surgeon: If an assistant surgeon was required for the procedure, this modifier should be appended.
11. Modifier 81 - Minimum Assistant Surgeon: Use this modifier if a minimum assistant surgeon was required.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): If an assistant surgeon was necessary due to the unavailability of a qualified resident surgeon, this modifier should be used.
13. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery: Use this modifier if a PA, NP, or CNS assisted in the surgery.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
The CPT code 42104, which pertains to the excision of a lesion on the roof of the mouth, is subject to reimbursement by Medicare. To determine if this specific CPT code is reimbursed, healthcare providers should refer to the Medicare Physician Fee Schedule (MPFS). The MPFS provides detailed information on the payment rates for services covered by Medicare. Additionally, it is important to consult with the relevant Medicare Administrative Contractor (MAC) for your region, as MACs are responsible for processing Medicare claims and can provide specific guidance on coverage and reimbursement policies for CPT code 42104.
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 42104. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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