CPT Code 68720

CPT code 68720 is a medical procedure code for creating a tear sac drain.

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What is CPT Code 68720

CPT code 68720 is used to describe a surgical procedure known as dacryocystorhinostomy. This procedure involves creating a new drainage pathway between the tear sac (dacryocyst) and the nasal cavity to allow tears to drain properly when the natural tear duct is blocked. This helps to relieve symptoms such as excessive tearing or chronic infections of the tear sac.

Does CPT 68720 Need a Modifier?

For CPT code 68720 (Dacryocystorhinostomy; without tube or stent insertion), the application of modifiers can be essential for accurate billing and reimbursement. Here are some common modifiers that might be used with this procedure, along with the reasons for each:

1. -50 Bilateral Procedure: This modifier is used when the procedure is performed on both sides of the body during the same operative session. It is important to check payer policies as some may adjust the reimbursement when this modifier is used.

2. -51 Multiple Procedures: Used when multiple procedures are performed during the same surgical session. This modifier indicates that this procedure is secondary or subsequent to the primary procedure. It may affect reimbursement rates depending on payer rules.

3. -52 Reduced Services: Applied when a service or procedure is partially reduced or eliminated at the physician's discretion. This could be relevant if the full dacryocystorhinostomy is not performed.

4. -53 Discontinued Procedure: Used when a procedure is terminated after the patient has been prepared but before anesthesia is administered, or after the administration of anesthesia due to extenuating circumstances or those that threaten the well-being of the patient.

5. -54 Surgical Care Only: Indicates that only the surgical portion of the procedure was performed by the reporting physician, typically used when another provider is handling postoperative management.

6. -55 Postoperative Management Only: Used when one physician performs the postoperative management and another physician performed the surgical procedure.

7. -56 Preoperative Management Only: Indicates that the physician only provided preoperative management and did not perform the surgery.

8. -57 Decision for Surgery: Added to indicate that the procedure resulted from and was performed during an evaluation for surgery. Typically used for procedures that occur within a day or so of the decision for surgery.

9. -58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: Used for procedures that are planned prospectively or are more extensive than the original procedure.

10. -59 Distinct Procedural Service: Indicates that procedures that are not normally reported together are appropriate under the circumstances. This can be crucial for procedures performed at different anatomical sites or different sessions.

11. -78 Return to the Operating Room for a Related Procedure During the Postoperative Period: Used when a second procedure is related to the first and requires a return to the operating room.

12. -79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Indicates that the procedure performed is not related to the original procedure.

13. -80 Assistant Surgeon: Used when a second surgeon provides assistance to the primary surgeon during the procedure.

14. -AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: Used specifically when a PA, NP, or CNS assists in surgery.

Each modifier has specific implications for billing and should be used accurately to convey the correct information to payers, ensuring appropriate reimbursement and compliance with billing regulations.

CPT Code 68720 Medicare Reimbursement

CPT code 68720, which refers to the procedure for creating a tear sac drain, is typically covered and reimbursed by Medicare when medically necessary. However, the specific amount of reimbursement can vary based on the geographic location and the setting in which the procedure is performed (e.g., outpatient facility vs. physician's office). To determine the exact reimbursement rate, it is advisable to consult the Medicare Physician Fee Schedule (MPFS) available on the Centers for Medicare & Medicaid Services (CMS) website or through Medicare Administrative Contractors (MACs) that manage claims and payments in specific regions.

Are You Being Underpaid for 68720 CPT Code?

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