2025 CPT code 21812

Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs.

The code includes thoracoscopic visualization. Modifier 50 should be appended for bilateral procedures.

Modifiers such as 22 (Increased Procedural Services), 50 (Bilateral Procedure), 52 (Reduced Services), 59 (Distinct Procedural Service), 76 (Repeat Procedure by Same Physician), 77 (Repeat Procedure by Another Physician), 78 (Return to the Operating Room for a Related Procedure), 79 (Unrelated Procedure by the Same Physician) may be applicable depending on the circumstances.

Medical necessity for this procedure is established by the presence of rib fractures requiring surgical stabilization, such as flail chest, significant pain, or failure of conservative management.

The physician makes an incision over the fractured ribs, realigns the bones, and stabilizes them with internal fixation devices. Thoracoscopic visualization may be used.The procedure includes prepping, anesthesia, incision, dissection, reduction, internal fixation, irrigation, bleeding control, wound closure.

IMPORTANT For 1-3 ribs, use 21811. For 7 or more ribs, use 21813. For a bilateral procedure, report 21812 with modifier 50.

In simple words: The provider treats four to six broken ribs on one side of the body through an open surgical approach.This involves making an incision to access the broken ribs, realigning the bones, and securing them with hardware like plates, screws, or wires. A thoracoscopy (a small camera inserted into the chest) may be used for better visibility during the procedure.

Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs. (For bilateral procedure, report 21812 with modifier 50)

Example 1: A patient sustained multiple rib fractures (4th, 5th, and 6th ribs) on the left side in a motor vehicle accident. Open reduction and internal fixation are performed using plates and screws, aided by thoracoscopic visualization., A patient with flail chest (multiple rib fractures) undergoes open repair of five ribs on the right side.Internal fixation is achieved with intramedullary rods., A patient fell from a height, fracturing the 4th, 5th, and 6th ribs on one side.The fractures are treated with open reduction and internal fixation using wires, along with thoracoscopic visualization.

Documentation should include details of the injury, number and location of fractured ribs, type of internal fixation used, operative report, and any intraoperative complications.

  • Revenue Code: P3D - MAJOR PROCEDURE, ORTHOPEDIC - OTHER
  • Payment Status: Active
  • Specialties:Thoracic Surgery, Trauma Surgery
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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