CPT Code 23395

CPT code 23395 is a medical code used to describe the procedure of muscle transfer in the shoulder or arm for billing and documentation purposes.

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What is CPT Code 23395

CPT code 23395 is used to describe a surgical procedure involving the transfer of muscle in the shoulder or arm. This code is typically utilized when a surgeon moves a muscle from one location to another within the shoulder or arm to restore function or improve mobility. This procedure may be necessary due to injury, disease, or congenital conditions affecting the muscles in these areas.

Does CPT 23395 Need a Modifier?

When billing for CPT code 23395 (Muscle transfer, any type, shoulder or upper arm), 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 23395, 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 factors such as increased complexity or time.

2. Modifier 50 - Bilateral Procedure
- Apply this modifier if the muscle transfer procedure was performed on both shoulders or arms during the same operative session.

3. Modifier 51 - Multiple Procedures
- Use this modifier when multiple procedures, including 23395, are performed during the same surgical session. This helps indicate that more than one procedure was carried out.

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

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

6. Modifier 62 - Two Surgeons
- Apply this modifier if two surgeons were required to perform the procedure together, each taking a distinct part of the surgery.

7. Modifier 66 - Surgical Team
- Use this modifier if the procedure required a surgical team due to its complexity.

8. Modifier 76 - Repeat Procedure by Same Physician
- This modifier is used if the same physician needs to repeat the muscle transfer procedure within a short period.

9. Modifier 77 - Repeat Procedure by Another Physician
- Apply this modifier if a different physician repeats the muscle transfer procedure within a short period.

10. 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 a related procedure during the postoperative period.

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

12. Modifier 80 - Assistant Surgeon
- Use this modifier if an assistant surgeon was necessary for the procedure.

13. Modifier 81 - Minimum Assistant Surgeon
- Apply this modifier if a minimum assistant surgeon was required for the procedure.

14. 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.

15. 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.

By appropriately applying these modifiers, healthcare providers can ensure that their claims for CPT code 23395 are accurately represented and reimbursed.

CPT Code 23395 Medicare Reimbursement

CPT code 23395 is reimbursed by Medicare, but the specifics of reimbursement can vary based on several factors. The Medicare Physician Fee Schedule (MPFS) provides a comprehensive list of services covered by Medicare, including the associated reimbursement rates. To determine the exact reimbursement for CPT code 23395, healthcare providers should refer to the MPFS.

Additionally, Medicare Administrative Contractors (MACs) play a crucial role in the reimbursement process. MACs are responsible for processing Medicare claims and can provide region-specific information regarding coverage and reimbursement rates for CPT code 23395. Providers should consult their respective MAC for detailed guidance on billing and reimbursement for this specific code.

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