CPT code 49204 is for excising an abdominal tumor larger than 5 cm, detailing the specific procedure for accurate billing and documentation.
CPT code 49204 is used to describe the excision of an abdominal tumor that measures over 5 centimeters in size. This procedure involves the surgical removal of the tumor along with any surrounding tissue that may be affected, ensuring that the margins are clear of cancerous cells. This code is typically utilized in cases where the tumor's size and location necessitate a more extensive surgical approach.
When using CPT code 49204 for the excision of an abdominal tumor over 5 cm, several modifiers may be applicable depending on the specific circumstances of the procedure. Below is a list of potential modifiers and the reasons for their use:
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 increased complexity or time.
2. Modifier 51 - Multiple Procedures
- Apply this modifier if multiple procedures were performed during the same surgical session. This helps indicate that more than one procedure was carried out.
3. Modifier 59 - Distinct Procedural Service
- Use this modifier to indicate that the procedure was distinct or independent from other services performed on the same day. This is often used to bypass National Correct Coding Initiative (NCCI) edits.
4. Modifier 62 - Two Surgeons
- This modifier is used when two surgeons work together as primary surgeons performing distinct parts of a single procedure.
5. Modifier 66 - Surgical Team
- Apply this modifier if the procedure required a surgical team due to its complexity.
6. Modifier 76 - Repeat Procedure by Same Physician
- Use this modifier if the same physician needs to repeat the procedure on the same day.
7. Modifier 77 - Repeat Procedure by Another Physician
- This modifier is used if a different physician repeats the procedure 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
- Apply this modifier 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 of the initial procedure.
10. Modifier 80 - Assistant Surgeon
- This modifier is used when an assistant surgeon is required for the procedure.
11. Modifier 81 - Minimum Assistant Surgeon
- Apply this modifier if a minimum assistant surgeon is required.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Use this modifier if an assistant surgeon is necessary because a qualified resident surgeon is not available.
13. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- This modifier is used when 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.
Determining whether CPT code 49204 is reimbursed by Medicare involves consulting the Medicare Physician Fee Schedule (MPFS) and the guidelines set forth by the Medicare Administrative Contractor (MAC) for your specific region. The MPFS provides a comprehensive list of services covered by Medicare, along with the corresponding reimbursement rates.
To verify if CPT code 49204 is reimbursed, you would need to check the MPFS database, which is accessible through the Centers for Medicare & Medicaid Services (CMS) website. Additionally, each MAC may have specific local coverage determinations (LCDs) that could affect reimbursement. Therefore, it is essential to review the LCDs provided by your regional MAC to ensure compliance with any local policies or additional documentation requirements.
In summary, while the MPFS and MAC guidelines are the primary resources for determining Medicare reimbursement for CPT code 49204, it is crucial to consult both to confirm coverage and understand any regional variations in policy.
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