CPT code 59857 is for an induced abortion procedure using vaginal suppositories and hysterotomy, covering hospital admission and related services.
CPT code 59857 is used to describe a medical procedure for an induced abortion where one or more vaginal suppositories, such as prostaglandin, are used to initiate the process. This procedure may or may not involve cervical dilation, which can be achieved using methods like laminaria. The code specifically applies when the procedure includes hospital admission and visits, as well as the delivery of the fetus and secundines (placenta and membranes). Additionally, this code is used when a hysterotomy is performed due to a failed medical evacuation, meaning that the initial method of inducing abortion was not successful, necessitating surgical intervention.
For CPT code 59857, the following modifiers may be applicable depending on the specific circumstances of the procedure and the billing requirements:
1. Modifier 22 - Increased Procedural Services: Use this modifier if the work required to perform the procedure is substantially greater than typically required. Documentation must support the substantial additional work and the reason for it.
2. Modifier 51 - Multiple Procedures: This modifier is used when multiple procedures are performed during the same surgical session. It indicates that the procedure is one of several performed.
3. Modifier 59 - Distinct Procedural Service: Apply this modifier to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is used to identify procedures that are not normally reported together but are appropriate under the circumstances.
4. Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: This modifier is used when the same procedure is repeated by the same provider subsequent to the original procedure.
5. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional: Use this modifier when a procedure is repeated by a different provider.
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 when a patient requires a return to the operating room for a related procedure during the postoperative period.
7. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: This modifier is used when a procedure performed during the postoperative period is unrelated to the original procedure.
8. Modifier 80 - Assistant Surgeon: This modifier is used when an assistant surgeon is required during the procedure.
9. Modifier 81 - Minimum Assistant Surgeon: Use this modifier when a minimum assistant surgeon is required.
10. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): This modifier is used when an assistant surgeon is necessary because a qualified resident surgeon is not available.
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 modifier should be used in accordance with payer-specific guidelines and documentation should support the use of any modifier applied to ensure proper reimbursement and compliance.
The CPT code 59857 is subject to reimbursement considerations under Medicare, but whether it is reimbursed depends on several factors, including coverage policies and medical necessity. The Medicare Physician Fee Schedule (MPFS) provides a framework for determining the reimbursement rates for services covered under Medicare Part B, but not all CPT codes are automatically covered.
For CPT code 59857, reimbursement by Medicare would typically require that the procedure is deemed medically necessary and falls within the coverage guidelines established by Medicare. Additionally, the specific reimbursement and coverage decisions can vary based on the Medicare Administrative Contractor (MAC) responsible for processing claims in a particular geographic region. Each MAC may have its own Local Coverage Determinations (LCDs) that provide further guidance on whether and under what circumstances a particular service is reimbursed.
Healthcare providers should consult the MPFS and the relevant MAC's policies to determine the specific reimbursement status of CPT code 59857 in their area. It is also advisable to verify any pre-authorization requirements or documentation needed to support the claim for this procedure.
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