Part B Insider (Multispecialty) Coding Alert

Published on Sun Apr 23, 2006 PDF

Caution:  Only use it when complications arise

You do have the option to report patient evaluations during the post-operative period; however, you need to understand the circumstances that allow you to do so.

CPT rules permit you to report an E/M service with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) if the surgeon evaluates the patient for a complication during the global period of a previous procedure.  
“Because payors following CPT guidelines do not consider postoperative infections as necessarily ‘related’ to the initial surgery, for instance, you can charge for an E/M service to evaluate the patient for a postoperative infection. However, you should use the 24 modifier to tell the payor that the E/M service is distinct and not a part of the global surgical package,” says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, NE. 

Medicare payors do not follow CPT guidelines with respect to modifier 24 and will only pay for treatment of complications during a global period if the complication results in a return to the operating room, says Susan Allen, CPC, compliance coder with JSA Healthcare in St. Petersburg, FL.
   
Example: Several days following hernia repair (for example, 49560, Repair initial incisional or ventral hernia; reducible) the patient develops an infection at the incision site. The patient visits the surgeon at her office. The surgeon inspects and opens the wound to drain the infection, changes the patient’s dressings and administers antibiotics.
 
For a private payor following CPT guidelines, you may report an E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 24 appended. The modifier indicates that the service is not included in the initial surgery’s global fee. 

For a Medicare payor, however, you must count the office visit as a part of the surgical package, and you cannot file a claim for additional reimbursement.    

Bottom line: Know whether your payor follows CPT or CMS guidelines before you report a postoperative complication service with modifier 24.