CPT Code 21194

CPT code 21194 is a medical code used to describe the reconstruction of the lower jaw with a graft.

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What is CPT Code 21194

CPT code 21194 is for the reconstruction of the lower jaw with a graft. This procedure involves surgically rebuilding the lower jawbone using a graft, which could be bone or other materials, to restore its structure and function.

Does CPT 21194 Need a Modifier?

When billing for CPT code 21194 (Reconstruction of lower jaw 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 21194, 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 complications or unusual circumstances during the surgery.

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 52 (Reduced Services):
- Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion. This could occur if the full extent of the planned surgery was not necessary.

4. Modifier 59 (Distinct Procedural Service):
- This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It helps to clarify that the procedures were separate and not part of a bundled service.

5. Modifier 62 (Two Surgeons):
- Apply this modifier if two surgeons were required to perform the procedure together, each acting as a primary surgeon. This is often necessary for complex surgeries that require specialized skills from both surgeons.

6. Modifier 66 (Surgical Team):
- Use this modifier if the procedure required a surgical team due to its complexity. This indicates that multiple providers were involved in the surgery, each contributing their expertise.

7. Modifier 76 (Repeat Procedure by Same Physician):
- This modifier is used if the same physician needs to repeat the procedure on the same day. It indicates that the procedure was necessary more than once within the same day.

8. Modifier 77 (Repeat Procedure by Another Physician):
- Apply this modifier if a different physician needs to repeat the procedure on the same day. This helps to distinguish between services provided by different practitioners.

9. 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 needs to return to the operating room for a related procedure during the postoperative period. This indicates that the return was unplanned and related to the initial surgery.

10. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period):
- Apply this modifier if an unrelated procedure is performed by the same physician during the postoperative period of the initial surgery. This helps to clarify that the new procedure is not related to the initial surgery.

11. Modifier 80 (Assistant Surgeon):
- Use this modifier if an assistant surgeon was necessary to help with the procedure. This indicates that another surgeon provided assistance during the surgery.

12. Modifier 81 (Minimum Assistant Surgeon):
- Apply this modifier if a minimum assistant surgeon was required for the procedure. This indicates that the assistance was minimal but necessary.

13. 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. This indicates that the assistance was necessary due to the unavailability of a resident.

14. Modifier AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery):
- Apply this modifier if a physician assistant, nurse practitioner, or clinical nurse specialist assisted in the surgery. This indicates that a non-physician provider was involved in the procedure.

By using the appropriate modifiers, healthcare providers can ensure accurate billing and reimbursement for the services provided under CPT code 21194.

CPT Code 21194 Medicare Reimbursement

Medicare reimbursement for CPT code 21194, which pertains to the reconstruction of the lower jaw with a graft, depends on several factors including the medical necessity of the procedure, the setting in which it is performed, and the specific Medicare plan of the patient. Generally, Medicare Part B may cover medically necessary surgical procedures, including reconstructive surgeries, if they are deemed essential for the patient's health and well-being.

However, it is crucial to verify the specific coverage details through the Medicare Administrative Contractor (MAC) for your region, as reimbursement rates and policies can vary. Additionally, the reimbursement amount can fluctuate based on geographic location, the complexity of the procedure, and other factors.

For the most accurate and up-to-date information, healthcare providers should consult the Medicare Physician Fee Schedule (MPFS) or contact their local MAC. As of the latest available data, the national average reimbursement rate for CPT code 21194 can be found in the MPFS, but it is advisable to check the current year's fee schedule for precise figures.

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