Oral maxillofacial / head & neck physician & facility ...

[Pages:4]oral maxillofacial / head & neck physician & facility coding & billing guide

2021 Medicare National Average Payments

Physician Reimbursement

CPT1 Code

CPT Code Description

Nerve Repair Coding Options

64910 Nerve repair; with synthetic conduit or vein allograft (e.g. nerve tube), each nerve

64912 Nerve repair; with nerve allograft, each nerve, first strand (cable)

RVUsA

20212

Payment

23.01 25.92

$803 $904

+64913B Nerve repair; with nerve allograft, each additional strand (List separately in addition to code for primary procedure)

5.19

$181

21244 21246 21247 21193 21194 21195 21196 21045 21046 21047 21048 21049 21454 21465 21470 21422 21423

21299

Maxillofacial Repair & Reconstruction Coding Options Reconstruction of mandible, extraoral, with transosteal bone plate (e.g. mandibular staple bone plate) Reconstruction of mandible or maxilla, subperiosteal implant; complete Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g. for hemifacial microsomia) Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation Excision of malignant tumor of mandible; radical resection Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (e.g. locally aggressive or destructive lesion[s]) Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (e.g. locally aggressive or destructive lesion[s]) Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (e.g. locally aggressive or destructive lesion[s]) Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (e.g. locally aggressive or destructive lesion[s]) Open treatment of mandibular fracture with external fixation Open treatment of mandibular condylar fracture Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints Open treatment of palatal or maxillary fracture (LeFort I type) Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches

Unlisted craniofacial and maxillofacial procedure

29.84 24.96 46.43 36.19 41.83 40.11 41.07 35.03 29.79 37.00 30.18 35.35 14.34 23.48 33.99 18.85 23.85

0

$1,041 $871

$1,620

$1,263 $1,460 $1,400 $1,433 $1,039 $968

$1,291

$1,053

$1,233

$500 $819

$1,186

$658

$832 Carrier Determined

ModifierC -22 -50 -51 -58 -59 -XE -XS -XP -XU

CPT/HCPCS Modifier Options Description Increased Procedural Service Bilateral Procedure Multiple Procedures Staged or Related Procedure or Service by Same Physician or Other Qualified Healthcare Professional During the Postoperative Period Distinct Procedural Service Separate Encounter Separate Structure Separate Practitioner Unusual Non-Overlapping Service

A. Total RVU (Relative Value Unit) ? Total includes work RVU, Practice Expense RVU and Malpractice RVU. Information presented herein reflects the Facility Setting. B. Report Add-on code +64913 with 64912. Do not report these codes with 69990 (includes operating microscope). Multiple procedure reduction guidelines may apply. C. The CPT codes in this Guide are unilateral procedures. If performed bilaterally, some payors require that the service be reported twice with modifier 50 appended to the second

code while others require identification of the service only once with modifier 50 appended. Check with individual payors.

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Outpatient Facility Reimbursement

CPT Code

HOPD APC Description

APC

HOPD SID

HOPD3 2021 Payment

Nerve Repair Coding Options

64910 64912

Level 2 Nerve Procedures Level 2 Nerve Procedures

5432

J1

5432

J1

$5,700 $5,700

+64913

Bundled into Primary C-APC Payment

-

N

No separate payment

Maxillofacial Repair & Reconstruction Coding Options

21244

Level 5 ENT Procedures

5165

J1

$5,086

21246 21247

Level 5 ENT Procedures Level 5 ENT Procedures

5165

J1

5165

J1

$5,086 $5,086

21193

Level 5 ENT Procedures

5165

J1

$5,086

21194 21195

Level 5 ENT Procedures Level 5 ENT Procedures

5165

J1

5165

J1

$5,086 $5,086

21045

Level 5 ENT Procedures

5165

J1

$5,086

21046 21047

Level 5 ENT Procedures Level 5 ENT Procedures

5165

J1

5165

J1

$5,086 $5,086

21048

Level 5 ENT Procedures

5165

J1

$5,086

21049 21454

Level 5 ENT Procedures Level 5 ENT Procedures

5165

J1

5165

J1

$5,086 $5,086

21465

Level 5 ENT Procedures

5165

J1

$5,086

21470 21422

Level 5 ENT Procedures Level 5 ENT Procedures

5165

J1

5165

J1

$5,086 $5,086

21423

Level 5 ENT Procedures

5165

J1

$5,086

21299

Level 1 ENT Procedures

5161

T

$212

ASC SIE

ASC4 2021 Payment

J8

$3,802

J8

$3,788

N1

No separate payment

J8

$3,296

A2

$2,399

Not covered

G2

$2,399

Not covered

J8

$3,604

Not covered

A2

$2,399

A2

$2,399

R2

$2,399

G2

$2,399

J8

$3,261

J8

$3,213

J8

$3,330

Not covered

Not covered

Not covered

HCPCS Level II Coding Options

HCPCS5 Code

HCPCS Code Description

C9399 L8699 C1762

Unclassified Drugs or Biologicals Prosthetic Implant, Not Otherwise Specified Connective Tissue, Human (Includes Fascia Lata)

Inpatient Facility Reimbursement

ICD-10-PCS Hospital Procedure Codes

ICD-10-PCS6 Code

Procedure Description

Nerve Repair Coding Options

00UK0KZ 00UM0KZ 00UP0KZ 00US0KZ 00UR0KZ 00UK0JZ 00UM0JZ 00UP0JZ 00US0JZ 00UR0JZ 00RK0KZ 00RM0KZ 00RP0KZ 00RS0KZ 00RR0KZ 00RK0JZ

Supplement Trigeminal Nerve with Nonautologous Tissue Substitute, Open Approach Supplement Facial Nerve with Nonautologous Tissue Substitute, Open Approach Supplement Glossopharyngeal Nerve with Nonautologous Tissue Substitute, Open Approach Supplement Hypoglossal Nerve with Nonautologous Tissue Substitute, Open Approach Supplement Accessory Nerve with Nonautologous Tissue Substitute, Open Approach Supplement Trigeminal Nerve with Synthetic Substitute, Open Approach Supplement Facial Nerve with Synthetic Substitute, Open Approach Supplement Glossopharyngeal Nerve with Synthetic Substitute, Open Approach Supplement Hypoglossal Nerve with Synthetic Substitute, Open Approach Supplement Accessory Nerve with Synthetic Substitute, Open Approach Replacement of Trigeminal Nerve with Nonautologous Tissue Substitute, Open Approach Replacement of Facial Nerve with Nonautologous Tissue Substitute, Open Approach Replacement of Glossopharyngeal Nerve with Nonautologous Tissue Substitute, Open Approach Replacement of Hypoglossal Nerve with Nonautologous Tissue Substitute, Open Approach Replacement of Accessory Nerve with Nonautologous Tissue Substitute, Open Approach Replacement of Trigeminal Nerve with Synthetic Substitute, Open Approach

D. HOPD Status Key: C = Inpatient only procedure; J1 = Comprehensive APC rules apply; all covered Part B services are packaged into a single payment; N = No separate payment; payment is packaged into payment for other services; Q1 = Packaged APC payment if billed on the same date of service as an HCPCS code assigned status indicator S, T, V; S = Significant procedure, not discounted when multiple procedure performed; T = Procedure, discounted 50% when another procedure with a T status is billed.

E. ASC Status Key: A2, G2, & R2: Payment based on OPPS relative payment rate and subject to the multiple procedure discount (50%); J8: Device-intensive procedure and subject to the multiple procedure discount (50%)

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Inpatient Facility Reimbursement

ICD-10-PCS Hospital Procedure Codes

ICD-10-PCS6 Code

Procedure Description

Nerve Repair Coding Options

00RM0JZ 00RP0JZ 00RS0JZ 00RR0JZ

Replacement of Facial Nerve with Synthetic Substitute, Open Approach Replacement of Glossopharyngeal Nerve with Synthetic Substitute, Open Approach Replacement of Hypoglossal Nerve with Synthetic Substitute, Open Approach Replacement of Accessory Nerve with Synthetic Substitute, Open Approach

0NBT0ZZ 0NBV0ZZ 0NRT07Z 0NRV07Z 0NQV0ZZ 0NQT0ZZ 0NRV0JZ 0NRT0JZ 0NTT0ZZ 0NTV0ZZ 0NDV0ZZ 0NDT0ZZ 0NQTXZZ 0NQVXZZ 0NRT0KZ 0NRV0KZ 0N5T0ZZ 0N5V0ZZ 0NTT0ZZ 0NTV0ZZ 0NQT0ZZ 0NQV0ZZ

Maxillofacial Repair & Reconstruction Coding Options Excision of Right Mandible, Open Approach Excision of Left Mandible, Open Approach Replacement of Right Mandible with Autologous Tissue Substitute, Open Approach Replacement of Left Mandible with Autologous Tissue Substitute, Open Approach Repair Left Mandible, Open Approach Repair Right Mandible, Open Approach Replacement of Left Mandible with Synthetic Substitute, Open Approach Replacement of Right Mandible with Synthetic Substitute, Open Approach Resection of Right Mandible, Open Approach Resection of Left Mandible, Open Approach Extraction of Left Mandible, Open Approach Extraction of Right Mandible, Open Approach Repair Right Mandible, External Approach Repair Left Mandible, External Approach Replacement of Right Mandible with Nonautologous Tissue Substitute, Open Approach Replacement of Left Mandible with Nonautologous Tissue Substitute, Open Approach Destruction of Right Mandible, Open Approach Destruction of Left Mandible, Open Approach Resection of Right Mandible, Open Approach Resection of Left Mandible, Open Approach Repair Right Mandible, Open Approach Repair Left Mandible, Open Approach

ICD-10-CM7 CodeF

S04.31XA S04.32XA S04.51XA S04.52XA S04.71XA S04.72XA S04.891A S04.892A

C41.1 C79.51 D16.5 D48.0 D49.2 M27.2

M87

ICD-10-CM Diagnosis Codes Diagnosis Description

Nerve Repair Coding Options Injury of Trigeminal Nerve, Right Side, Initial Encounter Injury of Trigeminal Nerve, Left Side, Initial Encounter Injury of Facial Nerve, Right Side, Initial Encounter Injury of Facial Nerve, Left Side, Initial Encounter Injury of Accessory Nerve, Right Side, Initial Encounter Injury of Accessory Nerve, Left Side, Initial Encounter Injury of Other Cranial Nerves, Right Side, Initial Encounter Injury of Other Cranial Nerves, Left Side, Initial Encounter

Maxillofacial Repair & Reconstruction Coding Options Malignant Neoplasm of Mandible Secondary Malignant Neoplasm of Bone Benign Neoplasm of Lower Jaw Bone Neoplasm of Uncertain Behavior of Bone and Articular Cartilage Neoplasm of Unspecified Behavior of Bone, Soft Tissue, and Skin Inflammatory Conditions of Jaws Osteonecrosis

D. ICD-10-CM Injury Codes ? The 7th character changes with encounter level. A=Initial Encounter. Only the initial encounter code is listed in this Guide. Additional codes exist for the other encounter levels.

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Inpatient Facility Reimbursement

ICD-10-CM7 CodeF

S02.600B S02.601B S02.602B S02.609B

ICD-10-CM Diagnosis Codes Diagnosis Description

Maxillofacial Repair & Reconstruction Coding Options Fracture of Unspecified Part of Body of Mandible, Unspecified Side, Initial Encounter for Open Fracture Fracture of Unspecified Part of Body of Right Mandible, Initial Encounter for Open Fracture Fracture of Unspecified Part of Body of Left Mandible, Initial Encounter for Open Fracture Fracture of Mandible, Unspecified, Initial Encounter for Open Fracture

MS-DRG 040 041 042 140 141 142 143 144 145

MS-DRG Description Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC Peripheral/Cranial Nerve and Other Nervous System Procedures with CC or Peripheral Neurostimulator Peripheral/Cranial Nerve and Other Nervous System Procedure without CC/MCC Major Head and Neck Procedures with MCC Major Head and Neck Procedures with CC Major Head and Neck Procedures without CC/MCC Other Ear, Nose, Mouth, and Throat O.R. Procedure with MCC Other Ear, Nose, Mouth, and Throat O.R. Procedure with CC Other Ear, Nose, Mouth, and Throat O.R. Procedure without CC/MCC

20218 Payment $23,317 $13,851 $11,105 $23,451 $13,005 $9,478 $17,461 $10,313 $7,149

F. ICD-10-CM Injury Codes ? The 7th character changes with encounter level. B - initial encounter for open fracture. Only the initial encounter code for an open fracture is listed in this Guide. Additional codes exist for the other encounter levels.

References: 1. CPT 2021 Professional Edition, 2020 American Medical Association (AMA); CPT is a trademark of the AMA 2.2021 Medicare Physician Fee Schedule, ; Last accessed January 2021 3. 2021 Medicare Outpatient Prospective Payment System, ; Last accessed December 2020 4. 2021 Medicare ASC Payment Rates, ; Last accessed December 2020 5. 2020 HCPCS, ; Last accessed December 2020 6. 2021 ICD-10-PCS ; Last accessed December 2020 7. 2021 ICD-10-CM ; Last accessed December 2020 8. 2021 DRG Expert, Optum 360, LLC

Disclaimer: The information is for educational purposes only and should not be construed as authoritative. The information is current as of December 2020 and is based upon publicly available source information. Codes and values are subject to frequent change without notice. The entity billing Medicare and/or third-party payors is solely responsible for the accuracy of the codes assigned to the services or items in the medical record. When making coding decisions, we encourage you to seek input from the AMA, relevant medical societies, CMS, your local Medicare Administrative Contractor and other health plans to which you submit claims. Items and services that are billed to payors must be medically necessary and supported by appropriate documentation. It is important to remember that while a code may exist describing certain procedures and/or technologies, it does not guarantee payment by the payors. ? 2021 Axogen Corporation Revolutionizing the science of nerve repair is a trademark of Axogen Corporation. MKTG-0073 R03

revolutionizing the science of nerve repairTM

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