CPT Code 21196

CPT code 21196 is for reconstructing the lower jaw with fixation, a surgical procedure to repair and stabilize the jawbone.

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What is CPT Code 21196

CPT code 21196 is for the surgical procedure of reconstructing the lower jaw (mandible) with fixation. This means that a surgeon will rebuild or repair the lower jaw and use devices such as plates, screws, or wires to hold the bone in place during the healing process.

Does CPT 21196 Need a Modifier?

When billing for CPT code 21196 (Reconstruction of lower jaw with fixation), 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 21196, 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. Documentation must support the increased complexity.

2. Modifier 52 - Reduced Services
- Apply this modifier if the procedure was partially reduced or eliminated at the physician's discretion. Documentation should explain the reason for the reduction.

3. Modifier 58 - Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
- Use this modifier if the reconstruction is part of a planned, staged series of procedures.

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 is often used to bypass National Correct Coding Initiative (NCCI) edits.

5. Modifier 62 - Two Surgeons
- Apply this modifier if two surgeons of different specialties are required to perform distinct parts of the procedure.

6. Modifier 66 - Surgical Team
- Use this modifier when the procedure requires a surgical team due to its complexity.

7. Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
- This modifier is used if the same procedure is repeated by the same provider.

8. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional
- Use this modifier if the procedure is repeated by a different provider.

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
- Apply this modifier if the patient needs to return to the operating room for a related procedure during the postoperative period.

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

11. Modifier 80 - Assistant Surgeon
- Apply this modifier if an assistant surgeon is required for the procedure.

12. Modifier 81 - Minimum Assistant Surgeon
- Use this modifier if a minimum assistant surgeon is required for the procedure.

13. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- This modifier is used when an assistant surgeon is necessary because a qualified resident surgeon is not available.

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

Proper use of these modifiers can help ensure that claims are processed correctly and that the healthcare provider receives appropriate reimbursement for the services rendered. Always refer to the latest coding guidelines and payer-specific policies for the most accurate and up-to-date information.

CPT Code 21196 Medicare Reimbursement

Medicare reimbursement for CPT code 21196, which pertains to the reconstruction of the lower jaw with fixation, depends on several factors including the specific Medicare plan, the medical necessity of the procedure, and the setting in which the procedure is performed (e.g., inpatient hospital, outpatient facility, or physician's office).

As of the latest available data, Medicare does reimburse for CPT code 21196 when it is deemed medically necessary. The reimbursement amount can vary based on geographic location and the specific Medicare Administrative Contractor (MAC) policies. For instance, the national average payment for this procedure in an outpatient setting can range from approximately $1,500 to $3,000. However, these figures are subject to change and should be verified with the latest Medicare fee schedule or through direct consultation with the relevant MAC.

Healthcare providers should ensure proper documentation and justification of medical necessity to facilitate reimbursement. Additionally, it is advisable to check the most current Medicare Physician Fee Schedule (MPFS) or contact the local MAC for precise reimbursement rates and any specific billing requirements.

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