CPT Code 21936

CPT code 21936 is a medical billing code for the surgical removal of a back tumor measuring 5 cm or larger.

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What is CPT Code 21936

CPT code 21936 is for the surgical procedure involving the resection (removal) of a tumor located in the back that is 5 centimeters or larger in size.

Does CPT 21936 Need a Modifier?

For CPT code 21936, which involves the resection of a back tumor measuring 5 cm or greater, the following modifiers may be applicable:

1. Modifier 22 (Increased Procedural Services): This modifier is used when the work required to perform the procedure is substantially greater than typically required. For instance, if the tumor is deeply embedded or if there are complications that make the surgery more complex, Modifier 22 can be appended to indicate the increased effort and resources.

2. Modifier 51 (Multiple Procedures): If multiple procedures are performed during the same surgical session, Modifier 51 should be used. This is common in cases where additional tumors are resected or other surgical interventions are necessary.

3. 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. For example, if another unrelated procedure is performed on a different site, Modifier 59 would be appropriate.

4. Modifier 76 (Repeat Procedure by Same Physician): If the same physician needs to repeat the procedure on the same day, Modifier 76 should be used. This might occur if there is a need to address additional tumor tissue that was not fully resected in the initial procedure.

5. Modifier 77 (Repeat Procedure by Another Physician): If a different physician repeats the procedure on the same day, Modifier 77 is applicable. This could happen in a multi-disciplinary team setting where another specialist needs to perform a follow-up resection.

6. Modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period): This modifier is used if the patient needs to return to the operating room for a related procedure during the postoperative period due to complications or incomplete resection.

7. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): If an unrelated procedure is performed by the same physician during the postoperative period of the initial surgery, Modifier 79 should be used.

8. Modifier 80 (Assistant Surgeon): If an assistant surgeon is required to help with the procedure, Modifier 80 should be appended to indicate the involvement of an additional surgeon.

9. Modifier 81 (Minimum Assistant Surgeon): This modifier is used when an assistant surgeon is required for a minimal part of the procedure.

10. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available)): If a qualified resident surgeon is not available and an assistant surgeon is necessary, Modifier 82 should be used.

11. 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.

Each of these modifiers serves a specific purpose and should be used appropriately to ensure accurate billing and reimbursement for the services provided.

CPT Code 21936 Medicare Reimbursement

When considering whether Medicare reimburses the CPT code 21936, which pertains to the resection of a back tumor measuring 5 cm or greater, it is essential to consult the Medicare Physician Fee Schedule (MPFS) and the National Correct Coding Initiative (NCCI) edits.

As of the latest updates, CPT code 21936 is generally reimbursed by Medicare, provided that the procedure is deemed medically necessary and is performed in accordance with Medicare guidelines. The reimbursement amount can vary based on several factors, including the geographic location of the service, the setting in which the procedure is performed (e.g., hospital outpatient department vs. physician's office), and any applicable modifiers.

For a precise reimbursement amount, healthcare providers should refer to the MPFS for the specific year in question. As an example, in 2023, the national average reimbursement for CPT code 21936 is approximately $1,200. However, this figure can fluctuate based on the aforementioned factors.

To ensure accurate billing and reimbursement, it is advisable for healthcare providers to verify the current rates and guidelines through the Centers for Medicare & Medicaid Services (CMS) website or consult with their billing department or RCM specialists.

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