How To Use CPT Code 21616

CPT code 21616 describes the excision of the first and/or cervical rib with sympathectomy. 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 21616?

CPT 21616 is a code used to describe the excision of the first and/or cervical rib with sympathectomy. This procedure is performed to treat conditions such as rib deformities or congenital abnormalities like thoracic outlet syndrome. The provider removes the rib and also performs a sympathectomy, which involves severing the sympathetic nerve chain to correct chronic pain or conditions like hyperhidrosis.

2. Official Description

The official description of CPT code 21616 is: ‘Excision first and/or cervical rib with sympathectomy.’

3. Procedure

During the procedure for CPT 21616, the patient is appropriately prepped and anesthetized. The provider makes an incision in the skin over the rib to be excised. The paravertebral muscles are divided horizontally, and the costotransverse joints are cleared of muscle attachments. The periosteum is incised, and the rib is cut from the joint using a bone cutting tool. The ligaments from the costotransverse joint are cut, and the rib is removed. The provider then focuses on the sympathetic nerve chain, opening the parietal pleura over the nerve at the selected level. A small segment of the ganglia, which contains nerve cells, is excised, and any accessory fibers of the nerve are ablated using electric current. The area is irrigated, checked for bleeding, and a drainage tube is inserted. The incision is closed in layers.

4. Qualifying circumstances

CPT 21616 is performed on patients with conditions such as rib deformities or congenital abnormalities like thoracic outlet syndrome. The procedure involves the excision of the first and/or cervical rib, as well as a sympathectomy. It is important to carefully review the documentation to ensure the presence of sympathetic nerve removal, as required with this code.

5. When to use CPT code 21616

CPT code 21616 should be used when the provider performs the excision of the first and/or cervical rib with sympathectomy. It is important to ensure that the documentation supports the necessity of this specific procedure for the patient’s condition.

6. Documentation requirements

To support a claim for CPT 21616, the provider must document the following information:

• Patient’s diagnosis and the need for the excision of the first and/or cervical rib with sympathectomy
• Details of the procedure, including the specific ribs excised and the level of sympathectomy performed
• Incision site and approach used
• Any complications or unexpected findings during the procedure
• Post-operative care instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21616, ensure that the documentation supports the excision of the first and/or cervical rib with sympathectomy. It is important to review the specific billing guidelines provided by the payer to ensure accurate reporting. Additionally, consider any modifiers that may be required for proper reimbursement.

8. Historical information

CPT code 21616 was added to the Current Procedural Terminology system on January 1, 1990. There have been several changes to the code over the years, including being added and removed from the Inpatient Only (IPO) list for Medicare. It is important to stay updated on any changes or updates to ensure accurate coding and billing.

9. Similar codes to CPT 21616

There are several similar codes to CPT 21616 that may be used in different scenarios. These include:

• CPT 21610: Excision of rib(s), partial, for tumor with chest wall reconstruction
• CPT 21611: Excision of rib(s), partial, for tumor without chest wall reconstruction
• CPT 21612: Excision of rib(s), complete, for tumor with chest wall reconstruction
• CPT 21613: Excision of rib(s), complete, for tumor without chest wall reconstruction
• CPT 21627: Excision of rib(s), partial, for trauma or fracture

9. Examples

1. A patient with thoracic outlet syndrome undergoes excision of the first rib with sympathectomy to relieve symptoms of pain and numbness in the upper extremities.
2. A patient with hyperhidrosis undergoes excision of the cervical rib with sympathectomy to reduce excessive sweating.
3. A patient with a rib deformity undergoes excision of the affected rib with sympathectomy to correct the abnormality and alleviate associated symptoms.
4. A patient with chronic pain undergoes excision of the first and cervical rib with sympathectomy to address the underlying cause of the pain.
5. A patient with a congenital anomaly involving an extra rib undergoes excision of the cervical rib with sympathectomy to correct the abnormality and improve overall function.
6. A patient with thoracic outlet syndrome and hyperhidrosis undergoes excision of the first and cervical rib with sympathectomy to address both conditions simultaneously.
7. A patient with chronic pain and hyperhidrosis undergoes excision of the first rib with sympathectomy to alleviate pain and reduce excessive sweating.
8. A patient with a rib deformity and thoracic outlet syndrome undergoes excision of the affected rib with sympathectomy to address both conditions and improve overall function.
9. A patient with hyperhidrosis and a congenital anomaly involving an extra rib undergoes excision of the cervical rib with sympathectomy to correct the abnormality and reduce excessive sweating.
10. A patient with chronic pain, hyperhidrosis, and a rib deformity undergoes excision of the first and cervical rib with sympathectomy to address all three conditions and improve quality of life.