How To Use CPT Code 21812

CPT 21812 describes the open treatment of rib fracture(s) with internal fixation, including thoracoscopic visualization when performed, for four to six ribs on one side of the body. 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 21812?

CPT 21812 is used to describe the open treatment of rib fracture(s) with internal fixation. This procedure involves the use of hardware, such as plates, screws, nails, and wires, to stabilize the fractured ribs. The provider may also perform a thoracoscopy, which is the examination of the chest cavity using a small incision and a video camera, to better visualize the procedure. CPT 21812 specifically applies to the treatment of four to six ribs on one side of the body.

2. Official Description

The official description of CPT code 21812 is: ‘Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral 4-6 ribs.’

3. Procedure

The procedure for CPT 21812 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision in the skin over the fractured ribs.
3. The provider dissects through the tissue and down to the affected ribs.
4. The provider realigns the fractured bones back into position using internal fixation devices such as plates, screws, nails, and wires.
5. The provider irrigates the area, checks for bleeding, removes any instruments, and closes the incision.

4. Qualifying circumstances

CPT 21812 is used for patients who have broken ribs, usually as a result of trauma. The procedure is performed when the patient has four to six fractured ribs on one side of the body. The use of internal fixation devices is necessary to stabilize the fractures. The provider may also perform a thoracoscopy for better visualization of the procedure.

5. When to use CPT code 21812

CPT code 21812 should be used when the provider performs the open treatment of four to six rib fractures on one side of the body using internal fixation techniques. This code should not be used for fractures involving one to three ribs or seven or more ribs, as there are separate codes for those scenarios (CPT 21811 and CPT 21813, respectively).

6. Documentation requirements

To support a claim for CPT 21812, the provider must document the following information:

• Patient’s diagnosis of rib fractures
• Number of ribs treated (four to six on one side of the body)
• Details of the internal fixation devices used
• Whether a thoracoscopy was performed and its findings
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 21812, ensure that the procedure involves the open treatment of four to six rib fractures on one side of the body using internal fixation techniques. If the procedure is performed bilaterally, append modifier 50 to the code. Imaging guidance should not be reported separately. It is important to review the specific payer guidelines for any additional billing requirements or modifiers.

8. Historical information

CPT 21812 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates to the code since its addition.

9. Similar codes to CPT 21812

There are several similar codes to CPT 21812 that describe different scenarios of rib fracture treatment. These include:

• CPT 21811: Open treatment of rib fracture with internal fixation, includes thoracoscopic visualization when performed, unilateral one to three ribs
• CPT 21813: Open treatment of rib fracture with internal fixation, includes thoracoscopic visualization when performed, unilateral seven or more ribs

9. Examples

1. A patient sustains fractures in five ribs on the left side of their body. The provider performs an open treatment using internal fixation techniques and a thoracoscopy for visualization.
2. Following a traumatic accident, a patient presents with fractures in six ribs on the right side of their body. The provider performs an open treatment using internal fixation devices without the need for a thoracoscopy.
3. A patient is involved in a sports-related injury and has four fractured ribs on the left side of their body. The provider performs an open treatment using internal fixation techniques and documents the procedure accordingly.
4. After a fall, a patient has fractures in three ribs on the right side of their body. The provider performs an open treatment using internal fixation devices and a thoracoscopy for better visualization.
5. A patient is involved in a car accident and sustains fractures in seven ribs on the left side of their body. The provider performs an open treatment using internal fixation techniques and a thoracoscopy to stabilize the fractures.
6. Following a fall from a height, a patient presents with fractures in two ribs on the right side of their body. The provider performs an open treatment using internal fixation devices and documents the procedure accordingly.
7. A patient is injured in a workplace accident and has fractures in six ribs on the left side of their body. The provider performs an open treatment using internal fixation techniques and a thoracoscopy for better visualization.
8. After a sports-related injury, a patient presents with fractures in five ribs on the right side of their body. The provider performs an open treatment using internal fixation devices and documents the procedure accordingly.
9. A patient is involved in a motorcycle accident and sustains fractures in four ribs on the left side of their body. The provider performs an open treatment using internal fixation techniques and a thoracoscopy to stabilize the fractures.
10. Following a fall, a patient has fractures in six ribs on the right side of their body. The provider performs an open treatment using internal fixation devices without the need for a thoracoscopy.