Medicare Compliance & Reimbursement

Hint: Review Medicare guidelines before submitting your claims.

Even the most seasoned coders struggle with the nuances of modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period). Knowing how to use this modifier correctly, however, is a significant component of evaluation and management (E/M) coding, as it allows the provider to obtain valuable reimbursement when they conduct an unrelated E/M service during the global period of another service.

Bust these myths to help you overcome common challenges surrounding modifier 24.

Myth: You Can Use Modifier 24 For Any Service Within the Post-Op Period

You should only append modifier 24 to an appropriate E/M code when an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure. Modifier 24 tells the payer that the surgeon is seeing the patient for a new problem.

Modifier 24 is only for use on E/M codes, and only for use during the postoperative period (10 days or 90 days). The very definition of the modifier states it plainly: “unrelated evaluation and management service.”

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

Additionally: Modifier 24 only applies to services the physician performs after the surgical procedure. If the physician performs an E/M service before a procedure, on the day of that procedure, you would need modifier 25 (for minor procedures) or modifier 57 (for major procedures). Modifier 57 (Decision for surgery) also applies to E/M services rendered the day before the major procedure. This is true provided that the E/M code is significant and separately identifiable.

Myth: Modifier 24 Doesn’t Work With Postoperative Services

When you report postoperative services to payers that follow CPT^® guidelines, you’ll need to append modifier 24 to the E/M code to indicate that the service took place during the surgery’s global period.

Pointer: Complications of surgery can be separate and billable in some cases, unless the payer is following Medicare rules. Medicare does not allow postoperative complications (hematoma, seroma, infection, etc.) to be reimbursed separately unless there is a need to return to the operating room. At that point, a different modifier comes into play.

CMS and CPT^® agree: If the physician must return to the operating room (OR) to treat a post-op complication, both Medicare and private payers will pay at a reduced rate when you append the appropriate modifier to the surgical CPT^® code describing the surgeon’s treatment of the postsurgical complication. If the surgeon returns to the operating room to surgically correct a postoperative complication during the global period of a previous surgery, the correct modifier is 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

Bottom line: Determining whether complications of the surgery/procedure count as unrelated, and therefore mean you’ll use 24, means you must know what the guidelines are for the insurance company being billed. Medicare considers all complications part of global unless the patient is taken back to the OR. Most commercial insurances, however, will allow complications to be billed during global with the modifier 24.