Modifier 24: Determine How Your Payer Defines “Unrelated”
Brush up on modifier 24 guidelines to ensure payment for postsurgical unrelated E/M services.
Standard postoperative care, including related evaluation and management (E/M), is not separately reportable, but an unrelated E/M service during the postsurgical period may be. To alert the payer that an E/M service provided during the global period is not related to the original procedure, you must append modifier 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period to the ancillary service code. But before you do, make sure you know how your payer defines “unrelated.”
Identify Payer Rules
Successful coding hinges on knowing the definitions and guidelines specific to each payer. This is especially true when assigning modifier 24. The CPT® code book instructs you to append modifier 24 when the same provider performs an unrelated 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’s included in the global surgical package due to how each defines “unrelated.”
To cut through the confusion, start by determining if your payer follows CMS or American Medical Association (AMA) guidelines, and, if possible, get their response in writing. Then, apply the following rules:
According to CMS, an E/M service provided during the global period of a procedure is unrelated, and thus modifier 24 applies, if:
- The E/M service is for treatment of a problem unrelated to the surgery (supported by a different ICD-10 code).
- The E/M service is for treatment of the underlying condition that prompted the procedure.
Under AMA guidelines, modifier 24 applies for a:
- Visit for a new problem unrelated to the procedure;
- Visit for treatment of the underlying condition that prompted the procedure; and
- Visit for treatment of complications, exacerbation, or recurrence.
Understand the Difference
CMS considers E/M services for pain control and wound care to be related to postoperative care, as is any complication that doesn’t require a return to the operating room (OR). In such cases, CMS bundles all complications arising from the original procedure into the global surgical package. Unlike CMS, CPT® allows that a separately billable E/M service may be warranted for wound care, pain management, or treatment of surgical complications.
Modifier 24 Do’s and Don’ts
Use modifier 24 with the appropriate level of E/M service for an unrelated E/M service performed beginning the day after the procedure, by the same physician, during the 10- or 90-day global period. Payers consider physicians in the same group practice (identified by the same tax identification number) and the same specialty to be the “same physician” used in the modifier’s descriptor. Make sure that any E/M service billed under modifier 24 has documentation to support that the service was unrelated. It must be clear whether the service was solely for the treatment of a new problem or underlying condition, or part of the standard post-op care for the original procedure.
Tip: Advise providers to separate the routine care included in the surgical package from the unrelated care in their documentation. Explain that this allows the coder to easily identify the elements of performed and 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.
Do NOT use modifier 24:
- When it’s not during the global period.
- When a different physician conducts the service.
- When the service is related to the original procedure.
Put Your Knowledge to the Test
Let’s practice these concepts with a few clinical scenarios.
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 there is no correlation between the shoulder pain and the hip replacement.
The provider documented a level 3, established, outpatient visit to evaluate the patient’s shoulder pain during the global period of the hip replacement. In this case, appropriate coding is 99213-24 Office or other outpatient visit for the evaluation and management of an established patient … 20-29 minutes of total time is spent on the date of the encounter.
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 and can be separately reimbursed. 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 cannot be separately reimbursed.
Example 3: A patient undergoes breast biopsy. 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. Therefore, it can be reported with modifier 24 appended and separately reimbursed.
Reporting Related E/M Services During the Global Period
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.
Use of modifier 24 in E/M coding may seem confusing at first, but the guidelines above should help. When you have a clear understanding of the global period for procedures and what your payer includes in the global surgical package, you will have a much easier time knowing when to assign modifier 24.
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