CPT Code 21025

CPT code 21025 is for the surgical excision of a portion of the lower jaw bone.

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What is CPT Code 21025

CPT code 21025 is for the surgical procedure involving the removal (excision) of a portion of the bone in the lower jaw (mandible). This code is used by healthcare providers to document and bill for this specific type of surgery.

Does CPT 21025 Need a Modifier?

For CPT code 21025 (Excision of bone, lower jaw), the following modifiers may be applicable depending on the specific circumstances of the procedure:

1. Modifier 22 - Increased Procedural Services: Use this modifier if the procedure required significantly greater effort than typically required.

2. Modifier 50 - Bilateral Procedure: If the excision of bone is performed on both sides of the lower jaw, this modifier should be appended.

3. Modifier 51 - Multiple Procedures: If multiple procedures are performed during the same surgical session, this modifier should be used.

4. Modifier 52 - Reduced Services: If the procedure was partially reduced or eliminated at the physician's discretion, this modifier should be applied.

5. 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.

6. Modifier 76 - Repeat Procedure by Same Physician: If the same procedure is repeated by the same physician, this modifier should be used.

7. Modifier 77 - Repeat Procedure by Another Physician: If the procedure is repeated by a different physician, this modifier should be appended.

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: Use this modifier if the patient returns 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: If an unrelated procedure is performed by the same physician during the postoperative period, this modifier should be used.

10. Modifier 80 - Assistant Surgeon: If an assistant surgeon is required for the procedure, this modifier should be appended.

11. Modifier 81 - Minimum Assistant Surgeon: Use this modifier if a minimum assistant surgeon is required.

12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): If an assistant surgeon is required because a qualified resident surgeon is not available, this modifier should be used.

13. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery: Use this modifier if the services of a PA, NP, or CNS are required for assistance during surgery.

Each of these modifiers provides additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.

CPT Code 21025 Medicare Reimbursement

When considering whether Medicare reimburses the CPT code 21025 for the excision of bone in the lower jaw, it is essential to refer to the Medicare Physician Fee Schedule (MPFS) and Local Coverage Determinations (LCDs) for specific guidance. Generally, Medicare does provide reimbursement for medically necessary surgical procedures, including those involving the excision of bone in the lower jaw, provided that the procedure meets the criteria for medical necessity and is performed by a qualified healthcare provider.

For CPT code 21025, the reimbursement amount can vary based on geographic location, the setting in which the procedure is performed (e.g., hospital outpatient department, ambulatory surgical center, or physician's office), and other factors such as the provider's participation status with Medicare.

As of the latest available data, the national average reimbursement rate for CPT code 21025 under the Medicare Physician Fee Schedule is approximately $500-$700. However, this amount can fluctuate, and it is advisable to consult the most recent MPFS or contact your Medicare Administrative Contractor (MAC) for precise and up-to-date reimbursement information.

To ensure accurate billing and reimbursement, healthcare providers should also verify that all necessary documentation is in place to support the medical necessity of the procedure, as Medicare audits and reviews can impact payment.

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