Modifier 24

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I am looking for different opinions on the proper use of modifier 24 as it pertains to preexisting comorbidities.
Is modifier 24 acceptablein the below examples:
1. A patient is being treated for htn and chf during the global period by the same surgeon that rendered a CABG.
2. A patient is being treated for uncontrolled diabetes during the global period by the same surgeon that rendered a BKA.
3. A patient is being treated for ESRD during the global period by the same surgeon that rendered a Nephrectomy.
4. A patient is being treated for RBBB and Afib during the global period by the same surgeon that rendered the Aneurysm Repair.
 

bdcoyne8

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I'm hoping that none of this is for a quiz...

All conditions correlate to the surgeries that are rendered. How are these above and beyond the procedure?

I just don't have enough information to help with the 24. All sound related to the procedures performed.

HTN and CHF are very common in CABG.
Amputations can be results from diabetes (where it's the same provider treating the diabetes, I have to assume that's why they did the amputation).
ESRD is renal decease with kidney removal being a treatment of such.
RBBB and Afib could be why they did the aneurysm repair. Unclear on that one.

I wouldn't feel comfortable applying a modifier 24 to any of these without knowing what else they did additionally and if these were the main reasons for the procedure, it has to be "unrelated".
 
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From my understanding, global payments are based on typical/normal surgical services. Although comorbidities are related to the condition that required surgery, they are not related to the surgery itself but are they a 'typical' part of recovery. We have many claims that have been paid this way, the question is, should we refund?
 

bdcoyne8

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I would still need to know exactly why those procedures were performed. If they amputation happened for the diabetes and he's discussing the diabetes, I would assume he would also be looking at the wound and what are they doing differently for the diabetes at that visit that they weren't previously doing? Was the diabetes the reason for the amputation? What is above and beyond that visit that makes it billable?

If they didn't do that amputation for the diabetes, then sure, a modifier 24 can be warranted. Without documentation, I wouldn't bill any with a 24! It's too hard to understand the background with just the little bit of info that is provided.
 
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It's hard to give details because I'm speaking in general terms. There seems to be so much grey and we cant find a solid "when to when not to" guideline, yet every claim we test billed to Medicare we received reimbursement for.
 

csperoni

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https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GloballSurgery-ICN907166.pdf
I would say each of these MAY be billable with -24. In your example #2, if the physician is managing the DM, that is treatment of the underlying condition that is not part of normal recovery from surgery. Any of the wound care, etc for the amputation I would exclude from E/M leveling. If the physician is NOT managing the DM, but uncontrolled DM is slowing the healing process, then not billable as that is a complication not requiring return to OR.
From the Medicare Global Surgery booklet full link above:
What services are included in the global surgery payment?
Medicare includes the following services in the global surgery payment when provided in addition to the surgery:
  • Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-operative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
  • Intra-operative services that are normally a usual and necessary part of a surgical procedure
  • All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room
  • Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
  • Post-surgical pain management by the surgeon
  • Supplies, except for those identified as exclusions
  • Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes
What services are not included in the global surgery payment?
The following services are not included in the global surgical payment. These services may be billed and paid for separately:
  • Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier “-57” (Decision for Surgery). This visit may be billed separately only for major surgical procedures.
  • Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record.
  • Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery
  • Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery
  • Diagnostic tests and procedures, including diagnostic radiological procedures
  • Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications
  • Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).
  • If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
  • Immunosuppressive therapy for organ transplants
  • Critical care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
 

csperoni

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PS - it is worth noting my post was regarding Medicare's global policy. CPT's definition of global is slightly different, and does allow for billing visits for complications. MOST carrier's follow the Medicare guidelines on this, but you should double check with your carriers.
 
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