CPT code 42806 is a code used to identify a biopsy procedure performed on the upper nose or throat for diagnostic purposes.
CPT code 42806 is used to describe a biopsy procedure performed on the upper nose or throat. This code indicates that a sample of tissue has been taken from this specific area for diagnostic purposes, allowing healthcare providers to examine the tissue for any abnormalities or diseases.
For CPT code 42806, 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 complications or other factors that increase the complexity of the procedure.
2. Modifier 50 - Bilateral Procedure: If the biopsy is performed on both sides of the upper nose/throat, this modifier should be used to indicate that the procedure was bilateral.
3. Modifier 51 - Multiple Procedures: If multiple procedures are performed during the same surgical session, this modifier should be used to indicate that more than one procedure was carried out.
4. Modifier 59 - Distinct Procedural Service: Use this modifier to indicate that the biopsy was a distinct procedural service from other services performed on the same day. This is particularly important if the biopsy is performed in conjunction with other procedures that are not typically reported together.
5. Modifier 76 - Repeat Procedure by Same Physician: If the biopsy needs to be repeated by the same physician on the same day, this modifier should be used.
6. Modifier 77 - Repeat Procedure by Another Physician: If the biopsy is repeated by a different physician on the same day, this modifier should be used.
7. 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 needs to return to the operating room for a related procedure during the postoperative period.
8. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: If an unrelated procedure is performed by the same physician during the postoperative period, this modifier should be used.
9. Modifier 80 - Assistant Surgeon: If an assistant surgeon is required for the procedure, this modifier should be used to indicate their involvement.
10. Modifier 81 - Minimum Assistant Surgeon: Use this modifier if a minimum assistant surgeon is required for the procedure.
11. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): This modifier is used when an assistant surgeon is necessary because a qualified resident surgeon is not available.
12. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: Use this modifier if a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery.
Each of these modifiers serves a specific purpose and should be used appropriately to ensure accurate billing and reimbursement.
The CPT code 42806 is reimbursed by Medicare, but it is essential to verify the specific reimbursement details through the Medicare Physician Fee Schedule (MPFS). The MPFS provides the payment rates for services covered by Medicare, including the CPT code 42806. Additionally, reimbursement can vary based on the region, as Medicare Administrative Contractors (MACs) may have different local coverage determinations and payment policies. Therefore, it is advisable to consult the relevant MAC for precise information on the reimbursement rates and any specific requirements for the CPT code 42806.
Discover how MD Clarity's RevFind software can meticulously read your contracts and detect underpayments down to the CPT code level, including specific codes like 42806, and by individual payer. Schedule a demo today to see how RevFind can ensure you're receiving the full reimbursement you deserve.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
