Modifier 24: How to Determine if an E/M Service Is “Unrelated”

Modifier 24: How to Determine if an E/M Service Is “Unrelated”

Payer rules differ with what’s considered an unrelated E/M service provided during the global period of a procedure.

Typically, an evaluation and management (E/M) service provided during the global period of a procedure is not separately reimbursed, but is bundled into payment for the procedure. An exception occurs when the E/M service is unrelated to the procedure. The challenge is knowing how individual payers define “unrelated.”

Identify Your Payer Rules

According to the Centers for Medicare & Medicaid Services (CMS), an E/M service provided during the global period of a procedure is unrelated if:

Evaluation and Management – CEMC

  • The E/M service is for treatment of a problem unrelated to the surgery
  • The E/M service is for treatment of the underlying condition that prompted the procedure

CMS considers E/M services for pain control and wound care to be related postoperative care, as is any complication that doesn’t require a return to the operating room (OR) (more on this, below).

The CPT® codebook likewise defines an unrelated E/M service as occurring for treatment of a problem unrelated to the surgery or for treatment of the underlying condition that prompted the procedure; but, unlike CMS, CPT® allows that a separately-billable E/M service may be warranted for wound care, pain management, or treatment of complications of surgery.

Example 1: A patient presents for a 30-day follow up after hip replacement. At that visit, the patient complains of a new onset of shoulder pain. The provider documents the elements of an E/M service to evaluate and treat the shoulder pain. Under both CPT® and CMS guidelines, this E/M service is unrelated to the previous procedure because the shoulder pain is not connected to the hip replacement.

Example 2: A patient presents for a 30-day follow up after hip replacement and complains of pain, swelling, and discharge at the site of the hip replacement. The provider documents the elements of an E/M service to evaluate and treat this complication. Under CPT® rules, the E/M service is “unrelated” to the hip replacement. Under CMS rules, the E/M service is related to the hip replacement because  it is for treatment of a complication of the previous procedure, and is not separately reimbursed.

Example 3: A patient undergoes breast biopsy (e.g., 19101 Biopsy of breast: open, incisional). The results reveal malignancy, and the patient returns within the 10-day global period to discuss treatment options. The provider documents the required elements of an E/M service. Under both CMS and CPT® guidelines, this E/M is “unrelated” to the previous biopsy because it is for treatment of the underlying condition that prompted the biopsy.

Medicare and Medicaid payers follow CMS guidelines. For all other payers, it’s up to you to determine which guidelines to follow.

Appending Modifier 24

To alert the payer that an E/M service provided during the global period is unrelated to the previous procedure, you must append modifier 24 Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period.

Let’s return to Example 1 and assume the provider documented a level 3, established, outpatient visit to evaluate the patient’s shoulder pain during the postoperative period of a hip replacement. In this case, appropriate coding is 99213-24 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity.

Remember: The definition of an “unrelated” (and thus, separately billable) E/M service may differ, depending on the payer, as previously explained.

Turn to Modifier 78 for
Complications Treated in the OR

If a provider returns a patient to the OR to treat complications during the global period, you may report the treatment separately by appending modifier 78 Return to the operating room for a related procedure during the postoperative period to the appropriate CPT® code. The rule applies regardless of payer.

Let’s return to Example 2 and assume the provider must return the patient to the OR during the global period to excise infected tissue at the incision site of the hip replacement. In this case, report the appropriate debridement code (e.g., 11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface) with modifier 78 appended.

Report Related E/M Services
During Global, without Payment

You may report related E/M services during the global period using CPT® 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure. Note that this code is for reporting purposes only; there is no reimbursement value associated with the code.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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