EM Coding Alert

RAC review sheds light on improper claims reported during global periods.

Think you know how to use modifiers correctly to collect for both an evaluation and management (E/M) visit and a procedure? If you're not keeping a close eye on the procedures' global periods, you might want to think again.

That's the word from Performant Recovery, an approved recovery audit contractor (RAC), who announced in January that it will be scrutinizing claims that violate Centers for Medicare and Medicaid (CMS) guidelines for E/M codes billed with procedures that have 0-, 10- and 90-day global periods.

So, before you risk being audited for incorrectly appending modifiers 24, 25, or 57 to an E/M service, heed this advice.

Problem: The RAC identified these three separate audit issues, as follows:

• E&M codes billed within a procedure code with a 0-day global period (endoscopies)  "Procedures with MPFS global days of 000 include only E/M services rendered on the day of surgery. Physicians can indicate that E/M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24, 25 and 57 on the E/M service."
• E/M codes billed with procedure codes that have 10-day global periods. "Procedures with MPFS global days of 10 include only E/M services on the day of the procedure and up to 10 post-operative days," Performant says on its website. "Physicians can indicate that E/M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24, 25, and 57 on the E/M service."
• E/M codes billed with procedure codes that have 90-day global periods. "Procedures with MPFS global days of 90 include only E/M services on the day before the procedure, the day of the procedure and up to 90 days post-operative days," Performant says. "Physicians can indicate that E/M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24, 25, and 57 on the E/M service."

3 Questions Show the Appropriate Use of Modifiers

Consider the following example, and then answer the three key questions below to ensure that you know how to code the above-referenced modifiers properly and to prevent your practice from landing on the RAC's radar screen.

Example: The pulmonologist sees a patient for difficulty breathing and chest tightness, and on x-ray, determines that the patient has a foreign body in her lung.

He decides to perform thoracotomy that same day, which he codes using 32150 (Thoracotomy; with removal of intrapleural foreign body or fibrin deposit). What is the best modifier that you can attach to the E/M service?

Question 1: Does the E/M Follow Another Service?

Answer:  No.In this situation, the E/M service happens prior to the surgery. Therefore, you would not choose modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period).

Reason: When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 to the appropriate E/M code. Modifier 24 tells the payer that the surgeon is seeing the patient for a new problem. Therefore, the plan should not include the E/M service in the previous procedure's global surgical package.

Rule: You cannot bill separately for E/M-related services during the global period. The global surgical package includes routine postoperative care during the global period.

Question 2: Was It a "Major" or "Minor" Procedure?

Answer: Major.Because the thoracotomy was a major service, then you should strike off modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) as an option.

Rationale: If the surgeon provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with zero-day, 10-day, or "XXX" global periods, you should append modifier 25 to the E/M code.

Question 3: Was the E/M Related to A Major Surgery?

Answer: Yes.

In the scenario above, the thoracotomy is "major" with a 90-day global period, and "related" to the E/M service the physician performs the day of or the day prior to the surgery. Therefore, you should append modifier 57 (Decision for surgery) to your E/M service code to indicate that this E/M service led to the decision for surgery.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M service into the global surgical package, leading to a loss in reimbursement. Without the modifier, the visit will appear to be the preoperative visit that the global surgical package includes.

An example of when not to append modifier 57 is when the decision for surgery occurred two days prior to surgery, but the physician still checks on an inpatient the day before and the day of surgery to ensure that the patient's condition has not changed and the plan for surgery is not contraindicated. Modifier 57 is not needed two days prior to surgery, and it is not appropriate to append it on the day before or the day of surgery (in this case) since the post-decision care is related and inclusive to the procedure.

Note: Since this is an automated review, the RAC will send a notice of the claims that are earmarked for refund. If you provide sufficient documentation to support your claim, the RAC will remove the claim from the list. Any unsupported claims will remain on the list that will be forwarded to the Medicare contractor for pursuit of refunds.

Resource: To read Performant's audit issues, visit >https://performantrac.com/audit-regions/region-1/?order=desc&filter=date_approved.