CPT Code 21245

CPT code 21245 is for the reconstruction of the jaw, detailing the specific medical procedure for accurate billing and insurance purposes.

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What is CPT Code 21245

CPT code 21245 is for the surgical procedure involving the reconstruction of the jaw. This code is used to document and bill for the complex process of rebuilding the jawbone, which may be necessary due to trauma, congenital defects, or other medical conditions affecting the jaw's structure.

Does CPT 21245 Need a Modifier?

When billing for CPT code 21245 (Reconstruction of jaw), 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 21245, along with the reasons for their use:

1. Modifier 22 - Increased Procedural Services
- Use this modifier when the work required to perform the procedure is substantially greater than typically required. Documentation must support the additional effort.

2. Modifier 50 - Bilateral Procedure
- Apply this modifier if the reconstruction of the jaw is performed bilaterally during the same operative session.

3. Modifier 51 - Multiple Procedures
- Use this modifier when multiple procedures, other than E/M services, are performed by the same provider during the same session.

4. Modifier 52 - Reduced Services
- This modifier is used when the procedure is partially reduced or eliminated at the physician's discretion.

5. Modifier 53 - Discontinued Procedure
- Apply this modifier if the procedure is discontinued due to extenuating circumstances or those that threaten the well-being of the patient.

6. Modifier 59 - Distinct Procedural Service
- Use this modifier to indicate that a procedure or service was distinct or independent from other services performed on the same day.

7. Modifier 62 - Two Surgeons
- This modifier is used when two surgeons work together as primary surgeons performing distinct parts of the procedure.

8. Modifier 66 - Surgical Team
- Apply this modifier when a team of surgeons is required to perform the procedure.

9. Modifier 76 - Repeat Procedure by Same Physician
- Use this modifier if the same physician performs the procedure again on the same day.

10. Modifier 77 - Repeat Procedure by Another Physician
- This modifier is used when a procedure is repeated by another physician on the same day.

11. 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 requires an unplanned return to the operating room for a related procedure during the postoperative period.

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

13. Modifier 80 - Assistant Surgeon
- This modifier is used when an assistant surgeon is required for the procedure.

14. Modifier 81 - Minimum Assistant Surgeon
- Apply this modifier when a minimum assistant surgeon is required for the procedure.

15. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Use this modifier when an assistant surgeon is required, and a qualified resident surgeon is not available.

16. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- This modifier is used when a non-physician provider assists in the surgery.

Proper use of these modifiers ensures accurate billing and helps avoid claim denials or delays. Always refer to the latest coding guidelines and payer-specific policies for the most accurate and up-to-date information.

CPT Code 21245 Medicare Reimbursement

Medicare reimbursement for CPT code 21245, which pertains to the reconstruction of the jaw, is contingent upon several factors, including medical necessity, the specific Medicare plan, and the setting in which the procedure is performed. Generally, Medicare Part B may cover this procedure if it is deemed medically necessary and is performed in an outpatient setting. However, the reimbursement amount can vary based on geographic location and other variables.

As of the most recent data, the national average reimbursement rate for CPT code 21245 under Medicare is approximately $1,500 to $2,000. It is essential to verify the exact reimbursement rate with the local Medicare Administrative Contractor (MAC) as rates can fluctuate and may be subject to specific conditions or adjustments.

For the most accurate and up-to-date information, healthcare providers should consult the Medicare Physician Fee Schedule (MPFS) or contact their MAC directly.

Are You Being Underpaid for 21245 CPT Code?

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