CPT code 42260 is a medical billing code used for the repair of a fistula between the nose and lip.
CPT code 42260 is used to describe the surgical procedure for repairing a fistula that forms between the nose and the lip. This code specifically indicates that the repair involves reconstructing the tissue to close the abnormal connection, which can help restore normal function and appearance.
For CPT code 42260 (Repair nose to lip fistula), 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 51 - Multiple Procedures
- Apply this modifier when multiple procedures are performed during the same surgical session. This indicates that the procedure is one of several performed.
3. Modifier 52 - Reduced Services
- Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion. Documentation should explain why the service was reduced.
4. Modifier 53 - Discontinued Procedure
- This modifier is appropriate if the procedure was started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
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 62 - Two Surgeons
- Apply this modifier when two surgeons work together as primary surgeons performing distinct parts of the procedure. Each surgeon should report their specific part of the procedure.
7. Modifier 66 - Surgical Team
- Use this modifier when a complex procedure requires the services of several physicians, often of different specialties, working together as a team.
8. Modifier 76 - Repeat Procedure by Same Physician
- This modifier is used if the same physician needs to repeat the procedure on the same day.
9. Modifier 77 - Repeat Procedure by Another Physician
- Apply this modifier if a different physician repeats the procedure on the same day.
10. 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 when the patient requires a return to the operating room for a related procedure during the postoperative period.
11. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- This modifier is used when an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
12. Modifier 80 - Assistant Surgeon
- Apply this modifier when an assistant surgeon is required for the procedure.
13. Modifier 81 - Minimum Assistant Surgeon
- Use this modifier when the assistant surgeon's involvement is minimal.
14. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- This modifier is used when a qualified resident surgeon is not available, and an assistant surgeon is necessary.
15. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Apply this modifier when a non-physician practitioner assists in the surgery.
Each of these modifiers 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.
The CPT code 42260, which involves a specific medical procedure, is subject to reimbursement by Medicare under certain conditions.
To determine if CPT code 42260 is reimbursed by Medicare, 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 essential 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 42260.
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 42260. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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