CPT Code 23430

CPT code 23430 is a medical code used to describe the surgical repair of a biceps tendon.

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What is CPT Code 23430

CPT code 23430 is used to describe the surgical procedure for repairing a biceps tendon. This code is specifically utilized when a healthcare provider performs a surgical intervention to fix a damaged or torn biceps tendon, which is a crucial tendon that connects the biceps muscle to the shoulder and elbow. The procedure aims to restore function and alleviate pain in the affected area.

Does CPT 23430 Need a Modifier?

When billing for CPT code 23430 (Repair biceps tendon), 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 23430, 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. Documentation must support the increased complexity or time.

2. Modifier 50 (Bilateral Procedure)
- Apply this modifier if the repair of the biceps tendon was performed on both arms 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. This indicates that multiple procedures were performed and may affect reimbursement.

4. Modifier 52 (Reduced Services)
- This modifier is used when the procedure is partially reduced or eliminated at the physician's discretion. Documentation should clearly indicate the reason for the reduction.

5. Modifier 59 (Distinct Procedural Service)
- Apply this modifier to indicate that the procedure was distinct or independent from other services performed on the same day. This is often used to bypass National Correct Coding Initiative (NCCI) edits.

6. Modifier 62 (Two Surgeons)
- Use this modifier when two surgeons work together as primary surgeons performing distinct parts of the procedure. Each surgeon should report their specific part of the procedure.

7. Modifier 66 (Surgical Team)
- This modifier is used when a complex procedure requires the expertise of a surgical team. Documentation should support the necessity of a team approach.

8. Modifier 76 (Repeat Procedure by Same Physician)
- Apply this modifier if the same physician needs to repeat the procedure on the same day.

9. Modifier 77 (Repeat Procedure by Another Physician)
- Use this modifier if a different physician repeats the procedure on the same day.

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)
- This modifier is used when the patient requires a 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)
- Apply this modifier if an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.

12. Modifier LT (Left Side)
- Use this modifier to indicate that the procedure was performed on the left side of the body.

13. Modifier RT (Right Side)
- Apply this modifier to indicate that the procedure was performed on the right side of the body.

14. 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.

Proper use of these modifiers ensures that claims are processed correctly and that healthcare providers receive appropriate reimbursement for their services. Always refer to the latest coding guidelines and payer-specific requirements when applying modifiers.

CPT Code 23430 Medicare Reimbursement

The reimbursement of CPT code 23430 by Medicare depends on its inclusion in the Medicare Physician Fee Schedule (MPFS) and the specific guidelines set forth by the Medicare Administrative Contractor (MAC) for your region. To determine if CPT code 23430 is reimbursed, healthcare providers should consult the MPFS, which lists the payment rates for services covered by Medicare. Additionally, it is essential to review the local coverage determinations (LCDs) and national coverage determinations (NCDs) provided by the MAC, as these documents offer detailed information on coverage criteria and any potential restrictions. By cross-referencing these resources, providers can ascertain whether CPT code 23430 is eligible for reimbursement under Medicare.

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