Know Your Payer to Make the Most of Modifier 24
Successful coding often means knowing what a payer wants.
The CPT® codebook instructs you to append modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period for an unrelated evaluation and management (E/M) service during the global period of a previous procedure. CPT® and the Centers for Medicare & Medicaid Services (CMS) agree the global surgical package includes routine, related postoperative care. But CMS and CPT® differ on what they include in the global surgical package.
To cut through the confusion, determine if your payer follows CMS or American Medical Association (AMA) guidelines (get the reply in writing, if possible). Then, apply the following rules.
Under CMS policy, modifier 24 applies for a:
- Visit for a new problem unrelated to surgery (must be supported by a different ICD-9-CM code)
- Visit for treatment of the underlying condition (not wound care, pain management, or a repeat procedure) that is not part of normal recovery from surgery.
Under AMA guidelines, modifier 24 applies for a:
- Visit for a new problem unrelated to surgery — supported by a different ICD-9-CM code;
- Visit for treatment of the underlying condition; and
- Visit for treatment of complications, exacerbations, or recurrence.
Here’s the Difference
CMS bundles into the global surgical package any complications arising from the original surgery, unless the complication requires a return to the operating room (OR). The Medicare Claims Processing Manual (chapter 12, section 30.6.6.A) instructs carriers, “Do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the surgeon is treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.” For Medicare payers, if the physician treats a patient for a post-operative infection during the global period, and the treatment does not require a return to the OR, the physician could not report a separate E/M service to Medicare.
AMA has stated that post-operative infection during the global period would qualify as a “new” (i.e., unrelated) problem because the diagnosis for the follow-up visit would be different from that which prompted the original procedure. Private payers who explicitly follow AMA guidelines may allow you to report a separate E/M service with modifier 24 if the physician tends to postoperative complications in the office.