Modifier 24: Appropriate Use

September 6, 2020Modifiers

Basics of Modifier 24

Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period

Modifier 24 is defined as an unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period. Medicare defines the same physician as physicians in the same group practice who are of the same specialty. In this instance, they must bill and be paid as though they were a single physician. The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of service. Modifier 24 is applied to two code sets:

E/M (Evaluation and management) services (99201-99499).
General ophthalmological services (92002-92014), which are eye examination codes.

Appropriate Use

Use Modifier 24 with the appropriate level of E/M service.
Use Modifier 24 on an E/M when:
- An unrelated E/M service is performed beginning the day after the procedure, by the same physician, during the 10 or 90-day post-operative period.
- Documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care.
- The same physician is managing immunosuppressant therapy during the post-operative period of a transplant.
- The same physician is managing chemotherapy during the post-operative period of a procedure.
Unrelated critical care performed by the same physician during the post-operative period.
The same diagnosis as the original procedure could be used for the new E/M if the problem occurs at a different anatomical site.

Inappropriate Use

Do not use Modifier 24 when:

The E/M is for a surgical complication or infection. This treatment is part of the surgery package.
The service is removal of sutures or other wound treatment. This treatment is part of the surgery package.
The surgeon admits a patient to a skilled nursing facility for a condition related to the surgery.
The medical record documentation clearly indicates the E/M is related to the surgery.
Outside of the post-op period of a procedure.
Services are rendered on the same day as the procedure
Reporting exams performed for routine postoperative care.
Reporting surgical procedures, labs, x-rays, or supply codes.

Each insurance company has their own sets of rules for processing claims with modifiers. Some of the responses you may experience include:

Denial of the claim as incidental to the service and leave it up to you to pursue appeal.
They may request proof that the service was unrelated to the minor or major surgery for which the postoperative period is applicable.
They can also pay the claim and then at a later date (sometimes up to three (3) years) request proof that the service actually qualified for modifier 24 and if not, request a refund of the monies paid.

Global Period and Modifier 24

The Medicare and CPT definition of the post-op global package are slightly different. Medicare states that unless a return trip to the operating room is required, all medical and surgical post-op complications are included in the global payment and may not be separately billed. Also, treatment of wound infections or other complications may not be reported to Medicare.

However, the CPT definition of the surgical package is ‘typical’ post-op care. This raises a question: If a payer follows CPT rules and not Medicare rules, can a surgeon report atypical post-op care for complications? Yes. Some practices use modifier 24 in this instance for E&M services for medical complications. Use the complication diagnosis code first on the claim form. However, it is critical that you check with your payer to be sure this follows its rules, because the definition of modifier 24, as developed by the AMA, is for unrelated care.

Other physicians who see the patient during the global period do not need to use modifier 24. If a patient in a surgical post-op period sees an internist, the internist does need to append a modifier to the E&M service. Only the operating physician, and his or her same-specialty partners or covering surgeons, need to use modifier 24.

Examples

Sometimes the patient scenario can be very complicated, requiring the coder to think through each scenario to determine applicable services and modifiers. Review the following scenario and see if you would have coded it correctly.

The patient comes in for a lesion removal, which has 10 postoperative global days. Four days later, the patient comes in for a new condition of upper respiratory infection (URI). Since the URI is a new, unrelated condition during the postoperative period, modifier 24 is appended to the E/M code. If modifier 24 is not appended to the E/M code, it will be denied as included in the global package of the surgery. The second diagnosis code must be unrelated to the lesion removal to allow for separate payment. Even though there are two separate unrelated diagnosis codes on the claim, the new diagnosis alone will not pay the claim. Destruction of premalignant lesion: 17000 E/M for upper respiratory infection (URI): 99213 24
The patient is 2 weeks status post laryngectomy for cancer and is seen in the surgeon’s office for EM service to begin chemotherapy for the next 6 weeks. Documentation supports an established visit level 99214.
An orthopedist treats a hip fracture on Dec. 15, and the patient returns with shoulder pain on Jan. 10. The Jan. 10 visit is separately reportable with modifier 24.

Use of the modifier 24 in E&M coding may seem confusing, but the guidelines above should help. When you clearly understand the global period for procedures, you will have a much easier time knowing when to assign modifier 24. Still not sure about the appropriate use of Modifier 24? Don’t worry E2E Medical Billing Services has an experienced coding team that uses exact modifiers to avoid denials. To know more about our medical billing services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com