Related or Not? Pass the Modifier 24 Paternity Test

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  • August 1, 2013
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When providers are doing the work for unrelated post-op procedures, get paid for it.

 By Erin Andersen, CPC, CHC
I had an opportunity to audit a surgical specialty that wondered if they could (or should) bill inpatient subsequent visits when seeing their patients after surgery.
Good question! The answer is, “Maybe.”
If the post-operative (post-op) visits are related to the surgery, the subsequent visits may not be billed separately. Whereas post-op visits unrelated to surgery should be billed with modifier 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period appended to the ancillary service code.

Questions to Consider

For what condition did the patient have surgery? If this is the same condition that is managed after surgery, it does not qualify for modifier 24 because it’s related. If the patient has arrhythmia, and that is the condition for which he had surgery, post-op visits for arrhythmia generally will not qualify for modifier 24. Whereas if the patient is managed for hypertension in the post-op period, but the surgery was for arrhythmia, this post-operative care might qualify.
Were the post-op conditions triggered by the surgery itself? This is a “you break it, you buy it” policy. For example, if the patient develops a post-op urinary tract infection from the Foley catheter placed during surgery, the post-op visits are not typically separately billable with modifier 24.
Were there other specialties also managing the same condition(s)? If the patient has diabetes and is managed by an endocrinologist post-operatively, it’s probably inappropriate for the surgeon to also bill for the management of this condition.
Were the post-op conditions due to complications from the surgery? If yes, these visits are included in the routine post-op care expected of the surgeon, unless there’s a return to the operating room to treat or diagnose the problem, which brings into play modifier 78 Unplanned return to the operating/procedure room by the same physician or other health care professional following initial procedure for a related procedure during the postoperative period.
In gathering answers to these questions, I came to understand that the physician assistants (PAs) working with the surgeons were acting like hospitalists for post-op patients. Sometimes, the PA was managing conditions unrelated to the condition for which the patient had surgery and unrelated to the surgery itself; and often the PA was the only person managing those conditions post-operatively. This led me to believe there might be an opportunity to bill the subsequent hospital visits with modifier 24, but I needed to look at the documentation to see if it supported what I was told.

Chart Notes Must 
Support Services

In reviewing the documentation, I found the history, exam, and medical decision-making (MDM) documented for the normal post-op care and the care for unrelated condition(s) were mixed together, making it difficult to see which elements were performed for each condition. This, in turn, made it difficult to determine the appropriate level of service. I call this “Frankenstein documentation,” i.e., merging elements of two different services (routine post-op care and unrelated care) to form a giant beast that makes no coding sense.

Improve Documentation 
to Improve Coding

In this case, I knew there were some billable situations, but the documentation was confusing. I recommended the routine care documentation to be separate from the care provided for the unrelated condition. I created a basic template for the providers to use, as shown in Figure A.
Figure A: Documentation Template
POD #:
Past 24-hour events:
Post-op Care
Unrelated Care
In addition to the normal post-op care provided today, we addressed the following unrelated conditions:
Separating the routine care included in the surgical package from the unrelated care allows the coder to easily identify the elements of history, exam, and MDM performed, and to select the appropriate level of service. Without separate documentation for the two types of care provided, the coder may inadvertently attribute an element of one to the other, leading to over-coding or under-coding.
It may take time for providers to get used to this style of documentation, but it should benefit them in the end. Using a template like this clearly shows the work not included in the global payment for the surgery; and it helps to make a stronger case for reporting visits with modifier 24.
The providers are already doing the work. With some documentation improvements, they may also bill for it.
Erin Andersen, CPC, CHC, is a compliance specialist at Oregon Health & Science University and has over 10 years of coding and compliance experience. She is the president of the Rose City Chapter in Portland, Ore., and a 2012-2015 Region 8 representative for the AAPCCA Board of Directors.

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