CPT Code 21145

CPT code 21145 is for a Lefort I-1 piece procedure with graft, used for billing and documentation in healthcare services.

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What is CPT Code 21145

CPT code 21145 is for a surgical procedure known as a LeFort I osteotomy, which involves making a horizontal cut above the teeth to separate the upper jaw (maxilla) from the rest of the facial bones. This specific code indicates that the procedure includes the use of a bone graft to aid in the reconstruction and stabilization of the jaw.

Does CPT 21145 Need a Modifier?

When billing for CPT code 21145 (LeFort I, one-piece with graft), it is essential to consider the appropriate use of modifiers to ensure accurate reimbursement and compliance with payer requirements. Below is a list of potential modifiers that could be used with CPT code 21145, along with 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 intensity, time, technical difficulty, or severity of the patient's condition.

2. Modifier 50 - Bilateral Procedure
- Apply this modifier if the procedure was performed bilaterally. This indicates that the same procedure was performed on both sides of the body.

3. Modifier 51 - Multiple Procedures
- Use this modifier when multiple procedures are performed during the same surgical session. This helps to indicate that more than one procedure was carried out.

4. Modifier 52 - Reduced Services
- This modifier is used when the procedure is partially reduced or eliminated at the physician's discretion. It indicates that the service provided was less than usually required.

5. Modifier 59 - Distinct Procedural Service
- Apply this modifier to indicate that a procedure or service was distinct or independent from other services performed on the same day. This is often used to bypass National Correct Coding Initiative (NCCI) edits.

6. Modifier 62 - Two Surgeons
- Use this modifier when two surgeons work together as primary surgeons performing distinct parts of the procedure. Each surgeon should report their distinct operative work.

7. Modifier 66 - Surgical Team
- This modifier is used when a complex procedure requires the services of a surgical team. It indicates that multiple providers were involved in the surgery.

8. Modifier 76 - Repeat Procedure by Same Physician
- Apply this modifier if the same physician needs to repeat the procedure on the same day. This helps to clarify that the repeat procedure was necessary.

9. Modifier 77 - Repeat Procedure by Another Physician
- Use this modifier when a different physician repeats the procedure on the same day. It indicates that the repeat procedure was performed by another provider.

10. 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 used if the patient needs to return to the operating room for a related procedure during the postoperative period.

11. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- Apply this modifier when an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.

12. Modifier 80 - Assistant Surgeon
- Use this modifier to indicate that an assistant surgeon was necessary for the procedure.

13. Modifier 81 - Minimum Assistant Surgeon
- This modifier is used when an assistant surgeon provides minimal assistance during the procedure.

14. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Apply this modifier when an assistant surgeon is necessary because a qualified resident surgeon is not available.

15. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Use this modifier when a non-physician provider assists in the surgery.

Each modifier serves a specific purpose and should be used accurately to reflect the services provided. Proper use of modifiers can help avoid claim denials and ensure appropriate reimbursement.

CPT Code 21145 Medicare Reimbursement

Determining whether Medicare reimburses a specific CPT code, such as 21145 (Lefort I-1 piece with graft), involves several steps. Medicare reimbursement is contingent on various factors, including medical necessity, the setting in which the procedure is performed, and the specific Medicare Administrative Contractor (MAC) policies.

For CPT code 21145, Medicare generally does provide reimbursement, but it is essential to verify the specifics through the Medicare Physician Fee Schedule (MPFS) or the relevant MAC. The reimbursement amount can vary based on geographic location and other factors.

As of the latest available data, the national average reimbursement rate for CPT code 21145 is approximately $1,500. However, this figure can fluctuate, and it is crucial to consult the MPFS or your MAC for the most accurate and up-to-date information.

To ensure proper reimbursement, healthcare providers should also ensure that all documentation supports the medical necessity of the procedure and adheres to Medicare's guidelines and policies.

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