How To Use CPT Code 21825

CPT 21825 describes the open treatment of a sternum fracture, with or without skeletal fixation. 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 21825?

CPT 21825 is used to describe the open treatment of a sternum fracture. This procedure involves accessing the fracture through an incision and may include the application of a fixation device to hold the bones in place during the healing process.

2. Official Description

The official description of CPT code 21825 is: ‘Open treatment of sternum fracture with or without skeletal fixation.’

3. Procedure

During the procedure for CPT 21825, the healthcare provider begins by making an incision in the chest and dissecting through the tissue to reach the affected rib. The provider then realigns the fractured bones back into position, using wires or screws if necessary. After the bones are properly aligned, the provider irrigates the wound and closes the incision.

4. Qualifying circumstances

CPT 21825 is used for patients who have sustained a sternum fracture that requires open treatment. This code is specifically for fractures of the sternum and does not apply to sternoclavicular dislocations. The procedure must be performed by a qualified healthcare provider and may involve the use of skeletal fixation devices.

5. When to use CPT code 21825

CPT code 21825 should be used when a patient requires open treatment for a sternum fracture. This code is appropriate when the provider surgically opens the fracture site to repair the break. If the provider does not make an incision, CPT code 21820, closed treatment of sternum fracture, should be reported instead.

6. Documentation requirements

To support a claim for CPT 21825, the healthcare provider must document the following information:

• Patient’s diagnosis of a sternum fracture
• Details of the open treatment procedure performed
• Description of any skeletal fixation devices used, if applicable
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider

7. Billing guidelines

When billing for CPT 21825, ensure that the procedure meets the criteria for open treatment of a sternum fracture. It is important to use the correct code based on the specific procedure performed. If the provider does not make an incision, CPT code 21820 should be reported instead. Additionally, consider the global period for follow-up care and use the appropriate modifiers if necessary.

8. Historical information

CPT code 21825 was added to the Current Procedural Terminology system on January 1, 1990. There have been several historical changes to the code, including its addition and removal from the Inpatient Only (IPO) list for Medicare.

9. Similar codes to CPT 21825

There are several similar codes to CPT 21825 that may be used for related procedures. These include:

• CPT 21820: Closed treatment of sternum fracture
• CPT 21830: Open treatment of sternoclavicular dislocation, with or without internal or external fixation
• CPT 21835: Closed treatment of sternoclavicular dislocation
• CPT 21840: Open treatment of sternoclavicular dislocation, with or without internal or external fixation, with or without repair of fractured clavicle
• CPT 21845: Closed treatment of sternoclavicular dislocation, with or without repair of fractured clavicle

9. Examples

1. A patient sustains a sternum fracture in a car accident and undergoes open treatment with the application of a fixation device.
2. An elderly patient falls and fractures their sternum, requiring open treatment to realign the bones.
3. A professional athlete fractures their sternum during a sports event and undergoes open treatment to ensure proper healing.
4. A patient with osteoporosis experiences a sternum fracture and requires open treatment to stabilize the bones.
5. A patient involved in a physical altercation sustains a sternum fracture and undergoes open treatment to repair the break.
6. A patient with a history of osteogenesis imperfecta fractures their sternum and requires open treatment for proper healing.
7. An individual involved in a workplace accident sustains a severe sternum fracture and undergoes open treatment to realign the bones.
8. A patient involved in a sports-related injury fractures their sternum and requires open treatment to ensure proper healing and prevent complications.
9. An elderly patient with weakened bones due to osteoporosis fractures their sternum and undergoes open treatment to stabilize the fracture.
10. A patient involved in a fall from a significant height sustains a sternum fracture and requires open treatment to repair the break.