Orthopedic Coding Alert

Focus on the surgeon's documentation, not the appointment book.

If you want to ensure you get paid for services your orthopedic surgeon performs after a major procedure while you're still billing in the global period of the procedure, you need to know the ins and outs of modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period:...). Even seasoned billers struggle with this modifier at times.

Overcome modifier 24 claim challenges by busting five myths that will lead to denial after denial if you fall into their billing trap. In part one of this two-part series, we'll bust the first two myths about when you should use modifier 24.

Myth #1: Modifier 24 Applies To Any Service Done In 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 problem unrelated to surgery. Therefore, the plan should not include the E/M service in the previous procedure's global surgical package.

Modifier 24 is "only for use on E/M codes, and only for use during the post-operative period (10 days or 90 days)," says Joseph Lamm, office manager with Stark County Surgeons, Inc. in Massillon, Ohio.

"The very definition of the modifier states it plainly: 'unrelated evaluation and management service,'" points out Charlotte T. Tweed, RHIA, CPC, coding auditor and inpatient/surgery coder in the department of medical education/coding at Florida Hospital in Orlando.

Rule: You cannot bill separately for E/M-related services relating 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 your physician performs after the surgical procedure. "If your physician performs an E/M service "before a procedure, on the day of that procedure, you would need a 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service:...) modifier (for minor procedures) or the 57 (Staged or related procedure or service by the same physician during the postoperative period:...) modifier (for major procedures)," Lamm explains. "The 57 (Decision for surgery) modifier also applies to E/M codes done the day before the major procedure. This is true provided that the E&M code is significant and separately identifiable."

Myth #2: Scheduled Office Visit Rules Out Modifier 24

Just because a patient was scheduled to come into your office for a follow-up visit related to the surgery, you shouldn't automatically assume you're unable to bill separate services using modifier 24.

Example: The surgeon removes a lump near the knee and later confirms the outgrowth to be a sarcoma of the bone. When the patient comes back in to the office for review, the sugeon does an extensive E/M service/office visit with the patient to discuss.

In this case, you "should be able to use modifier 24 to describe an E/M service unrelated to the surgery (only related to the disease process)," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. "CPT® would always allow this but even Medicare states that care directed at the underlying disease process is separately billable in the global period.

Key: Even though the visit initiated (was scheduled) as follow-up for surgery (i.e., for the sutures) you shouldn't think modifier 24 is out of the question. "People put too much emphasis on how a visit was scheduled," Bucknam says. "No one typically sees your clinic schedule. It's the documentation that counts. Additionally, no one would think that they shouldn't bill separately if the patient came in for follow up and also had a broken finger! It's the same thing, just more subtle."

Stay tuned: In the next issue of Orthopedic Coding Alert you'll learn the truth about three more modifier 24 myths and how you should properly use this modifier.