CPT code 49565 is for the surgical repair of a recurrent ventral hernia, involving the reduction of tissue back into the abdominal cavity.
CPT code 49565 is used to describe the procedure of repairing a ventral hernia that has been previously repaired but has recurred. This code indicates that the surgeon is performing a surgical intervention to reduce the hernia and restore the integrity of the abdominal wall. The procedure typically involves the removal of any scar tissue and the reinforcement of the area to prevent future herniation.
When using CPT code 49565 for the rerepair of a ventral hernia with reduction, 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 the complexity of the hernia repair or other complicating factors.
2. Modifier 51 - Multiple Procedures
- Apply this modifier if multiple procedures were performed during the same surgical session. This indicates that more than one procedure was carried out, which may affect reimbursement.
3. Modifier 58 - Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
- Use this modifier if the rerepair is part of a planned, staged procedure or if it is related to the initial surgery and performed during the postoperative period.
4. Modifier 59 - Distinct Procedural Service
- This modifier is used to indicate that the procedure is distinct or independent from other services performed on the same day. It helps to clarify that the rerepair of the ventral hernia is separate from other procedures.
5. Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
- Apply this modifier if the rerepair of the ventral hernia is a repeat procedure performed by the same physician. This indicates that the same procedure was necessary again.
6. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional
- Use this modifier if the rerepair was performed by a different physician. This helps to distinguish that the repeat procedure was carried out by another healthcare provider.
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
- This modifier is applicable if the patient had to return to the operating room unexpectedly for a related procedure during the postoperative period of the initial surgery.
8. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- Use this modifier if the rerepair of the ventral hernia is unrelated to the initial procedure and occurs during the postoperative period of the initial surgery.
9. Modifier 80 - Assistant Surgeon
- Apply this modifier if an assistant surgeon was necessary for the rerepair of the ventral hernia. This indicates that another surgeon assisted in the procedure.
10. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Use this modifier if an assistant surgeon was required because a qualified resident surgeon was not available.
11. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- This modifier is used when a non-physician provider assists in the surgery.
Each of these modifiers provides specific information that can affect billing and reimbursement, ensuring that the procedure is accurately represented and appropriately compensated.
Determining if CPT code 49565 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 49565 is reimbursed, you would need to check the MPFS database, which is accessible online through the Centers for Medicare & Medicaid Services (CMS) website. Additionally, MACs, which are private health care insurers that have been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries, may have specific local coverage determinations (LCDs) that could affect reimbursement.
In summary, to determine if CPT code 49565 is reimbursed by Medicare, you should review the MPFS and consult with your regional MAC for any specific guidelines or coverage determinations.
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