CPT Code 21558

CPT code 21558 is for the surgical resection of a neck tumor measuring 5 cm or larger.

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What is CPT Code 21558

CPT code 21558 is used for the surgical procedure to remove a tumor from the neck that is larger than 5 centimeters. This code specifically indicates that the tumor is being resected, which means it is being cut out or removed from the neck area.

Does CPT 21558 Need a Modifier?

When billing for CPT code 21558 (Resect neck tumor 5 cm/>), 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 21558, 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 the complexity of the tumor resection or unexpected complications during 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 59 (Distinct Procedural Service):
- Use this modifier to indicate that the procedure was distinct or independent from other services performed on the same day. This is particularly important if the resection was performed in conjunction with other unrelated procedures.

4. Modifier 62 (Two Surgeons):
- This modifier is used when two surgeons work together as primary surgeons performing distinct parts of the procedure. Each surgeon should report their specific part of the surgery.

5. Modifier 66 (Surgical Team):
- Apply this modifier if the procedure required a surgical team due to its complexity. This indicates that multiple professionals were involved in the surgery.

6. Modifier 76 (Repeat Procedure by Same Physician):
- Use this modifier if the same physician needs to repeat the procedure within a short period due to complications or recurrence of the tumor.

7. Modifier 77 (Repeat Procedure by Another Physician):
- This modifier is used if a different physician repeats the procedure within a short period due to complications or recurrence of the tumor.

8. Modifier 78 (Unplanned Return to the Operating Room):
- Apply 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.

9. 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 surgery.

10. Modifier 80 (Assistant Surgeon):
- This modifier is used when an assistant surgeon is required to help with the procedure. It indicates that another surgeon assisted the primary surgeon.

11. Modifier 81 (Minimum Assistant Surgeon):
- Apply this modifier if a minimum assistant surgeon was required for the procedure. This indicates limited assistance was provided.

12. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available)):
- Use this modifier if an assistant surgeon was necessary because a qualified resident surgeon was not available.

13. Modifier AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery):
- This modifier is used when a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery.

Each of these modifiers serves a specific purpose and should be used appropriately to ensure accurate billing and reimbursement for CPT code 21558. Always verify payer-specific guidelines as they may have unique requirements for modifier usage.

CPT Code 21558 Medicare Reimbursement

Determining whether Medicare reimburses a specific CPT code, such as 21558 (Resect neck tumor 5 cm/>), involves checking the Medicare Physician Fee Schedule (MPFS) and Local Coverage Determinations (LCDs) provided by Medicare Administrative Contractors (MACs).

For CPT code 21558, Medicare does provide reimbursement, but the amount can vary based on geographic location and other factors. As of the latest update, the national average reimbursement rate for CPT code 21558 is approximately $1,200. However, it is crucial to verify the exact reimbursement rate through the MPFS or your local MAC, as rates are subject to change and may differ based on specific circumstances.

To ensure accurate billing and reimbursement, healthcare providers should also review any applicable LCDs or National Coverage Determinations (NCDs) that might affect the coverage of this procedure.

Are You Being Underpaid for 21558 CPT Code?

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