Usage of Modifier 24 with surgical cpt codes

GLOBAL SURGERY MODIFIERS

Use the following modifiers pertaining to global surgery:

Modifier 24

24 Modifier Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: 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.

An E/M service can be coded with modifier 24 to indicate a visit in the postoperative period that is unrelated to the original procedure (surgery). This modifier is not valid when coded with surgeries or other types of services. It is not appropriate for modifier 24 to be coded with diagnostic tests performed in the postoperative period. These are not part of the global surgical allowance and are always considered separately.

In most cases, diagnosis codes that apply to the E/M service are different from the diagnosis codes indicated on the original procedure. However, in rare circumstances, the diagnoses are the same, but the services are unrelated; if so, this information should be documented with the claim, either in the narrative field on electronic claims or on an attachment with paper claims.

Hospital visits by the surgeon during the same hospitalization as the surgery are considered related to the surgery; however, separate payment for such visits can be allowed if one of the following conditions applies:

* Immunotherapy management furnished by the transplant surgeon. Immunosuppressant therapy following transplant surgery is covered separately from other postoperative services. That is, postoperative immunosuppressant therapy is not part of the global fee allowance for the transplant surgery. This coverage applies regardless of the setting.

* The surgeon provides critical care for a burn or trauma patient.

* The diagnosis is unrelated to the original surgery.

Outpatient visits during the postoperative period are allowed during a global fee period if the claim documentation demonstrates that the visit is for a diagnosis unrelated to the original surgery. Use modifier 24 in this situation.

Office visits during the postoperative period are not covered unless they are submitted with modifier 24 to indicate they are unrelated to the surgery. Modifier 24 is primarily for use only by the surgeon. A different diagnosis code may be sufficient to show the procedure is unrelated to the surgery; however, it may not be required. Documentation submitted should fully explain how the E/M service is unrelated to the surgical procedure.

Usage of Modifier - 24

Medical Coding - Modifier -24 --

Unrelated Evaluation and Management Service by the SamePhysician During Postoperative Period

Report E/M code 99213 with Modifier -24 if the patientcame back during the postoperative period. The physician must identifythis service as completely unrelated with the recent procedure done onthe patient. A detailed medical documentation is a good support formedical necessity.

Example:

A patient had a procedure, let's say, had an epidural 64483. The patient came back to the office after 2 days. The physician saw the patient and must bill an E/M code with modifier 24 if this encounter is completely unrelated to the procedure done 2 days ago. If this encounter is related to the procedure, you are not to bill the said E/M service because of the global package for the procedure. A follow up visit is always included during the global period.

Rules for Modifier 24 usage

Modifier 24 - Unrelated evaluation and management by the same physician during a postoperative period

The following rules apply:

    * Modifier 24 is applied to only two possible code sets: evaluation and management (E/M) services (99201-99499) or general ophthalmological services (92002-92014), which are eye examination codes.

    * Modifier 24 is not valid with surgical procedures, labs, x-rays, or supply codes.

    * The new E/M service or eye exam usually involves a different diagnosis, but not always. For example, the same diagnosis as the original procedure could be used for the new E/M if the problem occurs at a different anatomical site.

    * Modifier 24 is not used to report exams performed for routine postoperative care.

    * Modifier 24 is an information modifier.

Example

Dr. Smith sees an established patient in his office who had a bike accident. Dr. Smith performs an intermediate repair for a 4.0cm wound on the patient’s forehead. The repair has a 10-day global period. 

Three days later, the patient sees Dr. Smith complaining about sinus trouble. Dr. Smith performs a problem focused exam and diagnoses the patient with a sinus infection. He writes a prescription and codes the visit as a 99212-24.

24 Modifier usage with related diagnosis and unrelated DX

24 Modifier

Unrelated evaluation and management service by the same physician during a postoperative period

Use modifier 24 when an E/M service is performed during a postoperative follow-up period for reasons unrelated to the original minor or major procedure. The physician must indicate that the services billed are unrelated and not part of the postoperative diagnoses.

Examples of Related Diagnoses

Example 1: A surgical claim was billed with ICD-9-CM code 1622 (malignant neoplasm of trachea, bronchus and lung; main bronchus). Ten days later, a claim (for dates of service 10 days after a 90-day global surgery) is submitted by the same physician for an office visit and the ICD-9-CM used on the claim is 486 (pneumonia, organism unspecified).

This E/M service would be considered part of the global period and would not be payable.

Example 2: A surgical claim was billed with ICD-9-CM code 59653 (paralysis of the bladder). Eighty days later, a claim (for dates of service 80 days after a 90- day global surgery) is submitted by the same physician for an office visit and the ICD-9-CM code used on the claim was 78900 (abdominal pain, unspecified site).

This E/M service would be considered part of the global period and would not be payable.

Examples of Unrelated Diagnoses

Example 1: A surgical claim is billed with ICD-9-CM code 38421 (central perforation of tympanic membrane – ear drum). Two months later (during the 90-day global period), an E/M service is billed with ICD-9-CM code 3804 (impacted cerumen – ear wax).

This E/M service would be considered unrelated and would be payable.

Example 2: A surgical claim is billed with two 90-day global surgical codes for date of service July 9. The ICD-9-CM diagnoses submitted on the claim are 5533 (diaphragmatic hernia) and 56210 (diverticulosis of colon). An E/M service is performed and billed for date of service July 26. The ICD-9-CM codes submitted are 7872 (dysphagia – difficulty in swallowing), 7015 (other granulation tissue) and 78079 (other malaise and fatigue).

This E/M service would be considered unrelated and would be payable. If the E/M service is unrelated to the postoperative follow-up period, modifier 24 is appropriate.