CPT Code 21805

CPT code 21805 is a medical code used to describe the treatment of a rib fracture.

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What is CPT Code 21805

CPT code 21805 is used for the treatment of a rib fracture. This code specifically refers to the medical procedure where a healthcare provider addresses and manages a broken rib, ensuring proper alignment and healing.

Does CPT 21805 Need a Modifier?

When billing for CPT code 21805 (Treatment of rib fracture), 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 21805, along with the reasons for their use:

1. Modifier 22 (Increased Procedural Services)
- Use this modifier if the treatment of the rib fracture required significantly more work than typically required. This could be due to complications or unusual circumstances.

2. Modifier 50 (Bilateral Procedure)
- Apply this modifier if the treatment was performed on both sides of the body. This is relevant if rib fractures on both the left and right sides were treated during the same session.

3. Modifier 51 (Multiple Procedures)
- Use this modifier when multiple procedures are performed during the same surgical session. This helps indicate that more than one procedure was carried out, which can affect reimbursement.

4. Modifier 52 (Reduced Services)
- This modifier is appropriate if the procedure was partially reduced or eliminated at the physician's discretion. For example, if the full treatment was not necessary due to the patient's condition.

5. Modifier 59 (Distinct Procedural Service)
- Apply this modifier to indicate that the treatment of the rib fracture was distinct or independent from other services performed on the same day. This is useful when other procedures are performed that are not typically bundled with rib fracture treatment.

6. Modifier 76 (Repeat Procedure by Same Physician)
- Use this modifier if the same physician needs to repeat the treatment of the rib fracture within a short period. This indicates that the repeat procedure was necessary and performed by the same provider.

7. Modifier 77 (Repeat Procedure by Another Physician)
- Apply this modifier if another physician repeats the treatment of the rib fracture. This helps differentiate between the initial and subsequent treatments by different providers.

8. 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 additional treatment related to the initial rib fracture treatment during the postoperative period.

9. 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 rib fracture treatment.

10. Modifier 80 (Assistant Surgeon)
- Use this modifier if an assistant surgeon was necessary for the treatment of the rib fracture. This indicates that another surgeon assisted in the procedure.

11. Modifier 81 (Minimum Assistant Surgeon)
- Apply this modifier if a minimum assistant surgeon was required for the procedure. This is used when the assistance was less extensive than that indicated by Modifier 80.

12. 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.

13. 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.

Each of these modifiers serves a specific purpose and should be used accurately to reflect the services provided and ensure proper reimbursement. Always refer to the latest coding guidelines and payer-specific requirements when applying modifiers.

CPT Code 21805 Medicare Reimbursement

Medicare reimbursement for CPT code 21805, which pertains to the treatment of a rib fracture, is subject to specific guidelines and varies based on several factors including the setting of the service (e.g., inpatient, outpatient, or physician's office) and the geographical location. Generally, Medicare does cover the treatment of rib fractures, but the exact reimbursement amount can differ.

To determine if CPT code 21805 is reimbursed by Medicare and the specific amount, healthcare providers should refer to the Medicare Physician Fee Schedule (MPFS) or the relevant Medicare Administrative Contractor (MAC) for their region. These resources provide detailed information on covered services and the corresponding reimbursement rates.

For a precise reimbursement amount, providers can use the Medicare Physician Fee Schedule Lookup Tool available on the Centers for Medicare & Medicaid Services (CMS) website. This tool allows providers to input the CPT code and their specific locality to obtain the exact reimbursement rate.

In summary, while Medicare generally reimburses for the treatment of rib fractures under CPT code 21805, the exact amount varies and should be verified through the MPFS or the appropriate MAC.

Are You Being Underpaid for 21805 CPT Code?

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