CPT Code 20805

CPT code 20805 is a medical code used to describe the complete replantation of a forearm, essential for accurate billing and insurance claims.

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What is CPT Code 20805

CPT code 20805 is used to describe the surgical procedure for reattaching a completely severed forearm. This involves reconnecting bones, blood vessels, nerves, and other tissues to restore function and appearance.

Does CPT 20805 Need a Modifier?

For CPT code 20805 (Replant forearm complete), the following modifiers may be applicable depending on the specific circumstances of the procedure:

1. Modifier 22 - Increased Procedural Services
- Used when the work required to provide a service is substantially greater than typically required. This could be due to factors such as the complexity of the replantation or the patient's condition.

2. Modifier 51 - Multiple Procedures
- Applied when multiple procedures are performed during the same surgical session. This is relevant if additional surgeries are performed alongside the forearm replantation.

3. Modifier 52 - Reduced Services
- Used when a service or procedure is partially reduced or eliminated at the physician's discretion. This might apply if the replantation was not fully completed as initially planned.

4. Modifier 53 - Discontinued Procedure
- Applied when a procedure is started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient. This could be relevant if the replantation had to be halted for any reason.

5. Modifier 59 - Distinct Procedural Service
- Used to indicate that a procedure or service was distinct or independent from other services performed on the same day. This might be necessary if the replantation is performed in conjunction with other unrelated procedures.

6. Modifier 62 - Two Surgeons
- Applied when two surgeons work together as primary surgeons performing distinct parts of the procedure. This could be relevant if the complexity of the replantation requires the expertise of two surgeons.

7. Modifier 66 - Surgical Team
- Used when a team of surgeons is required to perform the procedure. This might be necessary for particularly complex replantations that require multiple specialists.

8. Modifier 76 - Repeat Procedure by Same Physician
- Applied if the same physician needs to repeat the replantation procedure. This could occur if the initial replantation was unsuccessful or complications arose.

9. Modifier 77 - Repeat Procedure by Another Physician
- Used if a different physician needs to repeat the replantation procedure. This might be relevant if the patient is transferred to another facility or specialist for the repeat procedure.

10. Modifier 78 - Unplanned Return to the Operating Room
- Applied when a patient requires an unplanned return to the operating room for a related procedure during the postoperative period. This could be necessary if complications arise from the initial replantation.

11. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- Used when a procedure or service performed during the postoperative period is unrelated to the original procedure. This might be relevant if the patient requires additional, unrelated surgical interventions during the recovery period.

12. Modifier 80 - Assistant Surgeon
- Applied when an assistant surgeon is required to help with the procedure. This could be necessary for particularly complex replantations.

13. Modifier 81 - Minimum Assistant Surgeon
- Used when a minimum assistant surgeon is required. This might be relevant for less complex replantations where only minimal assistance is needed.

14. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Applied when an assistant surgeon is required because a qualified resident surgeon is not available. This could be necessary in certain hospital settings.

15. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Used when a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery. This might be relevant in facilities where these professionals are part of the surgical team.

Each of these modifiers serves a specific purpose and should be used appropriately to ensure accurate billing and reimbursement for the services provided.

CPT Code 20805 Medicare Reimbursement

Medicare reimbursement for CPT code 20805, which pertains to the replantation of a complete forearm, is subject to specific criteria and guidelines. Generally, Medicare does cover this procedure, as it is considered medically necessary in cases of traumatic amputation where replantation is feasible and likely to restore function.

The reimbursement amount for CPT code 20805 can vary based on several factors, including geographic location, the specific Medicare Administrative Contractor (MAC), and the setting in which the procedure is performed (e.g., hospital outpatient department, inpatient setting). As of the latest available data, the national average reimbursement rate for this procedure under the Medicare Physician Fee Schedule (MPFS) is approximately $2,500 to $3,000. However, it is crucial to verify the exact reimbursement rate with the relevant MAC and consider any updates to the MPFS.

For the most accurate and up-to-date information, healthcare providers should consult the Medicare Fee Schedule Lookup Tool or contact their local MAC.

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