Pick the Correct E/M Modifier Every Time:
Here's How
Published on Wed Oct 12, 2005
Assign 57, not 25, for E/M prior to major surgical procedure
Your surgeon performs an E/M service on the same date as a procedure, so you reach for modifier 25, right? Not so fast. Ask yourself two questions first. Question 1: Does the E/M Follow Another Service? When an E/M service occurs during a postoperative global period, but for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated E/M service by the same physician during a postoperative period) to the appropriate E/M code.
By appending modifier 24, you make the payer aware that the surgeon is seeing the patient for a new problem, and therefore the payer should not include the E/M in the global surgical package of the previous procedure, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.
Modifier 24: Conditions for Use When you report modifier 24, the E/M service must meet these criteria:
- The E/M service occurs during the postoperative period of another procedure.
- The current E/M service is unrelated to the previous procedure.
- The same physician (or tax ID) who performed the previous procedure provides the E/M.
Remember: You cannot bill separately for related services during the global period. All payers include routine postoperative care during the global period in the global surgical package.
Example: A patient undergoes laryngectomy (31365, Laryngectomy; total, with radical neck dissection) for cancer of the larynx (161.9, Primary malignant neoplasm of the larynx [not elsewhere classified]). Laryngectomy is a major procedure, with a 90-day global period.
Several weeks later, the patient returns to the ENT with a new problem (for instance, 388.70, Otalgia, unspecified; earache NOS). The physician performs an evaluation for this new, distinct problem. In this case, you should append modifier 24 to the correct E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with a diagnosis of 388.70.
Learn more: For additional information on modifier 24, see -Call on 24 for Complication Evaluations--Maybe- later in this issue. Question 2: -Major- or -Minor- Procedure? When the surgeon decides to perform a procedure during an E/M service and provides the procedure on the same day (or, for major procedures, the same day or the next day), you can bill the E/M service separately. Depending on the length of the global period associated with the procedure, you should append either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery) to the appropriate E/M code.
Minor procedures mean 25: If the surgeon provides a significant, separately identifiable E/M service on the same date as a minor [...]
