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.

Evaluation and Management – CEMC

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.

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8 Responses to “Know Your Payer to Make the Most of Modifier 24”

  1. Julia, CPC says:

    Nice article. Very clear on Modifier 24.

  2. cindy tennille says:

    It seems confusing, if a patient developes an infection they cannot bill a visit, even though the
    ama is stating it would qualify as a “new” problem and unrelated to the surgery. Do you mean the doctor could bill it?

  3. chandani says:

    Can Federally qualified health centers use 24 modifier?

  4. Karin MHV/MBC says:

    What I read is that an infection is a new problem because the Dx changes and like Cindy states the AMA is stating it would qualify as new problem and unrelated. I find it confessing can we or not add the 24 modifier?

  5. Purva Sobti says:

    So true. It does confuse. What if a patient has hemmorroid surgery and in post op period he has rectal bleeding. Does he qualify for 24 modfier?

  6. john says:

    This is confusing because CPT and CMS (the AMA and Medicare payers, respectively) disagree on what counts as an “unrelated” service during the global period. That’s really the issue that the post is getting at.

    Under CPT/AMA guidelines, an infection during the post-op period is an unrelated problem because the diagnosis would be different from that which prompted the original surgery. If your payer follows CPT/AMA guidelines, you could report an office visit during the post-op period for that problem by appending modifier 24 to the appropriate E/M code.

    Under CMS/Medicare rules, an infection during the post-op period is related to the original surgery (even though the infection diagnosis would be different from the diagnosis that prompted the original surgery). CMS/Medicare will not pay separately for an office visit to address the infection; instead, it assumes such care is paid as part of the global surgical reimbursement.

    CMS/Medicare does allow you to report care during the post-op period that requires a return to the operating room, however; in such as case, you would have to apply modifier 78 to the appropriate surgical code.

    So, once again, the bottom line is: Payers have different rules for the use of modifier 24, and how/when you’ll append the modifier depends on your payers’ guidelines. In general, any payer that follows CMS rules (including Medicare payers) allows you to use modifier 24 in fewer circumstances, and will bundle a greater number/variety of services into the global surgical package.

    All of this (and the original article) apply to physician billing only, not facility billing.

  7. Mari says:

    How do you know which payers follow AMA guidelines vs. CMS guidelines?

  8. Dana says:

    Could someone further define “underlying condition”?

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