CPT Code 25426

CPT code 25426 is a medical billing code used for the repair or grafting of the radius and ulna bones in the forearm.

Accelerate your revenue cycle

Boost patient experience and your bottom line by automating patient cost estimates, payer underpayment detection, and contract optimization in one place.

Get a Demo

What is CPT Code 25426

CPT code 25426 is used for the surgical procedure involving the repair or grafting of the radius and ulna, which are the two long bones in the forearm. This code is specifically utilized when a surgeon performs a complex reconstruction to restore the normal function and structure of these bones, often due to fractures, deformities, or other significant injuries. The procedure may involve the use of grafts, which are pieces of bone or synthetic material, to aid in the healing and stabilization of the affected area.

Does CPT 25426 Need a Modifier?

When billing for CPT code 25426 (Repair/graft radius & ulna), it is essential to consider the appropriate use of modifiers to ensure accurate reimbursement and compliance with payer requirements. Below is a list of modifiers that could be used with CPT code 25426, 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 complications or unusual circumstances that necessitate additional time and effort.

2. Modifier 50 (Bilateral Procedure)
- Apply this modifier if the procedure was performed on both the left and right sides during the same operative session.

3. Modifier 51 (Multiple Procedures)
- Use this modifier when multiple procedures are performed during the same surgical session. This helps indicate that the primary procedure was accompanied by additional procedures.

4. Modifier 52 (Reduced Services)
- This modifier is used when the procedure is partially reduced or eliminated at the physician's discretion. It indicates that the service provided was less than usually required.

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 distinct operative work.

7. Modifier 66 (Surgical Team)
- This modifier is used when a complex procedure requires the services of a surgical team. It indicates that multiple professionals were necessary to complete the surgery.

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 when 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 an unplanned 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 when the procedure performed is unrelated to the original procedure and occurs during the postoperative period.

12. Modifier 80 (Assistant Surgeon)
- Use this modifier when an assistant surgeon is required to help perform the procedure.

13. Modifier 81 (Minimum Assistant Surgeon)
- This modifier is used when an assistant surgeon provides minimal assistance during the procedure.

14. Modifier 82 (Assistant Surgeon (when qualified resident surgeon not available))
- Apply this modifier when an assistant surgeon is necessary because a qualified resident surgeon is not available.

15. Modifier AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery)
- Use this modifier when a non-physician provider assists in the surgery.

By appropriately applying these modifiers, healthcare providers can ensure accurate billing and optimize reimbursement for the services rendered.

CPT Code 25426 Medicare Reimbursement

The CPT code 25426 is reimbursed by Medicare, but it is essential to verify the specific reimbursement details through the Medicare Physician Fee Schedule (MPFS). The MPFS provides a comprehensive list of services covered by Medicare and their corresponding reimbursement rates. Additionally, it is crucial to consult with your regional Medicare Administrative Contractor (MAC) to confirm any local coverage determinations or specific billing guidelines that may affect reimbursement for CPT code 25426. Each MAC may have unique policies that could influence the reimbursement process, so staying informed through these resources is vital for accurate and timely payment.

Are You Being Underpaid for 25426 CPT Code?

Discover the power of MD Clarity's RevFind software to ensure you're receiving the full reimbursement you deserve. With RevFind, you can read your contracts and detect underpayments down to the CPT code level and by individual payer. For example, if you're billing for CPT code 25426, RevFind will identify any discrepancies in payments, ensuring accuracy and maximizing your revenue. Schedule a demo today to see how RevFind can optimize your revenue cycle management.

Get paid in full by bringing clarity to your revenue cycle

Full Page Background