How To Use CPT Code 21615

CPT code 21615 describes the excision of the first and/or cervical rib to treat conditions such as rib deformities or congenital abnormalities like thoracic outlet syndrome. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21615?

CPT 21615 is used to describe the excision of the first and/or cervical rib. This procedure is performed to treat conditions such as rib deformities or congenital abnormalities like thoracic outlet syndrome. The provider removes the upper rib through an incision in the skin, clears the costotransverse joints, and carefully avoids damage to the sympathetic nerve chain.

2. Official Description

The official description of CPT code 21615 is: ‘Excision first and/or cervical rib.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision in the skin over the rib to be excised.
3. The paravertebral muscles are divided horizontally.
4. The provider clears the costotransverse joints of muscle attachments and incises the periosteum.
5. The rib is cut from the joint with a bone cutting tool.
6. The ligaments from the costotransverse joint are cut and the rib is removed.
7. The provider irrigates the area, checks for bleeding, and inserts a drainage tube if necessary.
8. The incision is closed in layers.

4. Qualifying circumstances

CPT 21615 is performed on patients with rib deformities or congenital abnormalities such as thoracic outlet syndrome. The procedure is typically done by a qualified healthcare professional who has the necessary expertise in performing rib excisions. It is important to note that if the sympathetic nerve removal is also performed during the procedure, CPT code 21616 should be reported instead.

5. When to use CPT code 21615

CPT code 21615 should be used when the provider performs the excision of the first and/or cervical rib to treat rib deformities or congenital abnormalities like thoracic outlet syndrome. It is important to ensure that the documentation clearly supports the medical necessity for the procedure.

6. Documentation requirements

To support a claim for CPT 21615, the healthcare professional must document the following information:

• Patient’s diagnosis and the medical necessity for the rib excision
• Details of the procedure, including the specific rib(s) excised
• Incision site and approach used
• Any additional procedures performed during the same operative session
• Any complications or unexpected findings
• Post-operative care instructions
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 21615, ensure that the documentation supports the medical necessity for the procedure. It is important to accurately report the specific rib(s) excised and any additional procedures performed during the same operative session. If the sympathetic nerve removal is also performed, report CPT code 21616 instead. Follow the appropriate coding guidelines and modifiers as required by the payer.

8. Historical information

CPT 21615 was added to the Current Procedural Terminology system on January 1, 1990. It has undergone several changes, including being added and removed from the Inpatient Only (IPO) list by Medicare.

9. Examples

1. A patient with thoracic outlet syndrome undergoes the excision of the first rib to relieve compression on the nerves and blood vessels in the upper extremities.
2. A patient with a congenital rib deformity undergoes the excision of the cervical rib to alleviate symptoms and improve functionality.
3. A patient with a rib tumor requires the excision of the first rib along with chest wall resection to remove the tumor and preserve lung function.
4. A patient with a rib tumor undergoes the excision of multiple ribs, chest wall resection, and reconstruction to achieve complete tumor removal and restore chest wall integrity.
5. A patient with a rib tumor requires the excision of multiple ribs, chest wall resection, mediastinal lymphadenectomy, and radical pleurectomy to achieve complete tumor removal and prevent further spread.