Separate Diagnosis Key to Successful Use of Modifier -24
Published on Sun Aug 01, 1999
Like any treatment directly related to the original procedure, routine complications following surgery are included in global surgery.
However, depending on the carrier and the particular circumstances, both examinations and surgical procedures for non-routine complications may be billable if they are reported with new primary diagnoses, as are new problems with new primary diagnoses, says Georgeann Edford, RN, MBA, president of Coding Compliance Solutions, a physician reimbursement consulting firm in Detroit, MI.
Lets say a patient has a cancer of the larynx (161.9, primary malignant neoplasm of the larynx [not elsewhere classified]) and the physician performed a 31365 (laryngectomy; total, with radical neck dissection), an extensive procedure with a 90-day global period.
The patient returns to the physician inside the 90 days, complaining about difficulty swallowing. The problem might, or might not, be related to the procedure. There also may be some scarring, or it could be some advancement of the disease that was treated, but there is no way for the physician to know until he does an exam. At that point, the physician discovers that its really not related to the procedure, its not scarring, and its really not advancement of the disease.
Under these circumstances, there would be a new diagnosis code, and Medicare, as well as some commercial carriers, can be billed for an evaluation and management (E/M) visit at the appropriately documented level using modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period).
The Health Care Financing Administration (HCFA) guidelines state that services submitted with the -24 modifier must be sufficiently documented to establish that the visit was unrelated to the surgery. An ICD-9 code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable documentation.
It is important to contact individual payers to find out whether they will accept the -24 modifier in the scenario described above. If the commercial carrier does accept the modifier -24, it should be obtained in writing to ensure the carrier doesnt subsequently deny the submitted claim.
Edford says the critical factor in determining whether modifier -24 may be used is the diagnosis. If, for example, the same patient had come back to the physician complaining about redness and swelling in the area of the incision, and the doctor performed an examination and found an infected suture, the E/M would not be billable because it would be considered related to the original procedure.
Edford says otolaryngologists have more difficulty with this modifier than many other specialists because most ailments they see are in the same general area.
A sore throat, for example, may or may not be related to an ear problem, and the physician is unlikely to know until [...]
