How To Use CPT Code 21720

CPT code 21720 describes the division of the sternocleidomastoid muscle in the neck to treat torticollis, a condition characterized by a stiff neck and muscle spasms that cause the head to tilt to one side. 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 21720?

CPT 21720 is used to describe the division of the sternocleidomastoid muscle in the neck to treat torticollis. This procedure is performed by a healthcare provider to alleviate the symptoms of a stiff neck and muscle spasms that cause the head to tilt to one side. It does not involve the application of a cast.

2. Official Description

The official description of CPT code 21720 is: ‘Division of sternocleidomastoid for torticollis, open operation without cast application.’

3. Procedure

During the procedure, the healthcare provider makes an incision above the medial end of the clavicle (collar bone). They expose the sternocleidomastoid muscle and make an incision into the tendon sheath. The provider then draws the tendon outside of the wound and cuts the ends. They confirm the absence of any remaining contracted muscle and ensure restoration of the patient’s neck movement. The area is irrigated, checked for bleeding, instruments are removed, and the incision is closed.

4. Qualifying circumstances

CPT 21720 is performed on patients with torticollis, a condition characterized by a stiff neck and muscle spasms that cause the head to tilt to one side. The procedure is indicated when conservative treatments have failed to alleviate the symptoms, and the division of the sternocleidomastoid muscle is deemed necessary. It is important to note that this procedure does not involve the transection of spinal accessory and cervical nerves, which are coded separately.

5. When to use CPT code 21720

CPT code 21720 should be used when a healthcare provider performs the division of the sternocleidomastoid muscle in the neck to treat torticollis. It is important to ensure that the procedure is performed without the application of a cast, as this would require a different code. This code should only be used when the specific criteria for the procedure are met.

6. Documentation requirements

To support a claim for CPT 21720, the healthcare provider must document the following information:

• Patient’s diagnosis of torticollis
• Details of the procedure performed, including the incision site and the division of the sternocleidomastoid muscle
• Confirmation of the absence of remaining contracted muscle
• Restoration of the patient’s neck movement
• Confirmation of irrigation, absence of bleeding, removal of instruments, and closure of the incision

7. Billing guidelines

When billing for CPT 21720, ensure that the procedure performed is the division of the sternocleidomastoid muscle for torticollis without the application of a cast. It is important to follow the specific guidelines and criteria for this code to ensure accurate billing. There are no specific guidelines regarding reporting CPT 21720 with other codes.

8. Historical information

CPT 21720 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 21720

There are several similar codes to CPT 21720 that are used for other procedures on the neck and thorax. These include:

• CPT 21685: Excision or curettage of bone cyst or benign tumor of the neck or thorax
• CPT 21700: Division of the sternum
• CPT 21705: Division of the sternum with fixation
• CPT 21740: Excision of chest wall tumor or cyst
• CPT 21750: Excision of chest wall tumor or cyst with plastic reconstruction

9. Examples

1. A healthcare provider performs the division of the sternocleidomastoid muscle in the neck to treat torticollis in a patient who has not responded to conservative treatments.
2. A patient with torticollis undergoes the division of the sternocleidomastoid muscle without the application of a cast to alleviate their symptoms.
3. A healthcare provider performs the division of the sternocleidomastoid muscle in a patient with torticollis, restoring their neck movement and relieving their muscle spasms.
4. A child with torticollis undergoes the division of the sternocleidomastoid muscle to correct their head tilt and improve their neck mobility.
5. A healthcare provider performs the division of the sternocleidomastoid muscle in a patient with severe torticollis, resulting in improved head alignment and reduced muscle spasms.
6. A patient with chronic torticollis undergoes the division of the sternocleidomastoid muscle to alleviate their symptoms and improve their quality of life.
7. A healthcare provider performs the division of the sternocleidomastoid muscle in a patient with congenital torticollis, correcting their head tilt and improving their neck mobility.
8. A teenager with torticollis undergoes the division of the sternocleidomastoid muscle to alleviate their symptoms and improve their posture.
9. A healthcare provider performs the division of the sternocleidomastoid muscle in a patient with acquired torticollis, resulting in improved neck mobility and reduced muscle spasms.
10. A patient with torticollis undergoes the division of the sternocleidomastoid muscle to correct their head tilt and improve their overall function.