EM Coding Alert

Remember: Scheduled office visit doesn't rule out modifier 24.

The physician provides an evaluation and management (E/M) service for a patient within the global period of the surgical procedure. Do you know if the service meets the requirements for appending modifier 24?

Test your modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) smarts with the following quiz to safeguard your payment for these services.

Can You Use Modifier 24? Find Out

Question 1: When should you append modifier 24 to an E/M service?

Answer 1: You should only attach modifier 24 to an appropriate E/M code when the physician renders the E/M service during a 10 or 90-day postoperative global period for reasons unrelated to the patient's surgery.

Modifier 24 only applies to services your physician performs after the surgical procedure. If the physician performs an E/M service on the same day as another procedure, you could look to modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) for minor procedures or modifier 57 (Decision for surgery) for major procedures. Modifier 57 also applies to E/M codes done the day before the major procedure. This is true provided that the E/M code is significant and separately identifiable.

Only Append Modifier 24 to These Codes

Question 2: To which codes can you append modifier 24?

Answer 2: You can append modifier 24 to any E/M code 99201-99499 and general ophthalmological services (92002-92014), which are eye examination codes.

If the E/M Service is Related to Original Surgery, Don't Append Modifier 24

Question 3: Can you append modifier 24 if the E/M service is related to the original surgery like a complication or infection?

Answer 3: No. You cannot bill separately for E/M-related services relating to the original surgery during the global period. A surgical complication or infection is considered part of the surgery package. When you append modifier 24, you are telling the payer that the surgeon is seeing the patient for a problem unrelated to surgery. Therefore, the medical record must support that the E/M visit was unrelated to the postoperative care, and the diagnosis should clearly indicate the reason for the unrelated postoperative encounter.

Some third-party payers will consider services provided for some complications. Touch base with them before submitting the claim.

Confirm Same Physician Performs Both Services for E/M-24

Question 4: When it comes to appending modifier 24, who must perform the E/M service?

Answer 4: You will use modifier 24 if the same physician who performed the original surgical procedure sees the patient during the postoperative period for an E/M service unrelated to the surgery.

In fact, If the patient reports for any unrelated E/M that occurs during a postop global period - including hospital visits, office visits, etc. - you must append modifier 24, according to Celia Forde, CPC, CPCH, coding specialist for Florida's Centra Care, which has offices in the Orlando area.

Scheduled Office Visit Doesn't Rule Out Modifier 24

Question 5: If a patient is scheduled for an office follow-up post-operative visit related to his surgery, does that automatically mean you cannot bill for a separate service using modifier 24?

Answer 5: No. Look at this example for clarity.

Example:  A patient has a biopsy of a lesion. When the patient returns a week later for suture removal, he is notified that the pathological examination revealed a malignant tumor. The physician, then, has a face-to-face discussion with the patient concerning new extended treatment for the tumor. The physician bills an E/M office visit based on the time he spent with the patient counseling him on the necessary therapy and coordinating his further treatment.

In this case, you should use modifier 24 to describe an E/M service unrelated to the surgery (only related to the disease process), says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, manager of clinical compliance with PeaceHealth in Vancouver, Washington. "CPT® would always allow this, but even Medicare states that care directed at the underlying disease process is separately billable in the global period."

Key:  Even though the visit was scheduled as a follow-up post-operative visit, you can use modifier 24 to ensure payment when the above clinical circumstances occur. "People put too much emphasis on how a visit was scheduled," Bucknam says. "No one typically sees your clinic schedule. It's the documentation that counts. Additionally, no one would think that they shouldn't bill separately if the patient came in for follow up and also had a broken finger! It's the same thing, just more subtle."

The one cautionary issue around the schedule is if your electronic record is connected to the schedule and automatically adds edits that need to be reviewed prior to claim submission, adds Suzan Hauptman, MPM, CPC, CEMC, CEDC AAPC fellow, senior principal of ACE Med Group in Pittsburgh.