EM Coding Alert

Question: A patient came to our practice seeking a second opinion during the 90-day global period of a surgery performed by another surgeon. What CPT^® code and modifier would be appropriate in this circumstance?

AAPC Forum Participant

Answer: The answer to your question really depends on the professional relationship between the surgeon who performed the initial surgery and the provider who performed the second encounter. It also depends on what the second provider actually does in that second session. To see how both things play out, consider the following general scenarios.

Scenario 1: Two providers, billing under the same tax ID number and specialty. The second provides normal postoperative care for a prior procedure performed be the first provider during the global period for the first procedure.

In this situation, a payer may view the second service as if it were performed by the same provider as the first and may decide that the second service is not billable. The key here is to determine the nature of the second service. If the purpose of the second encounter is to provide normal care to aid in the recovery or deal with the usual postoperative complications that are a result of the first procedure, then the second service, when performed by a provider connected to the first by common tax IDs, is included in the first service’s global package and cannot be separately billed.

Scenario 2: Two providers, different tax ID number and/ or specialty. The second provides normal postoperative care for a prior procedure performed by the first provider during the global period for the first procedure.

In this situation, the second provider can bill separately for the service. No modifier is necessary.

Scenario 3: Two providers, same tax ID number and specialty. The second provides care for a problem unrelated to the postoperative care for a prior procedure performed by the first provider during the global period for the first procedure.

In this situation, the second provider can bill separately for the service. If that service is an evaluation and management (E/M) service, you must append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period). The key in this situation is to understand what constitutes an “unrelated” E/M service in the payer’s eyes, and provide appropriate documentation to support it.

Scenario 4: Two providers, different tax ID number and/or specialty. The second provides care for a problem unrelated to the postoperative care for a prior procedure performed by the first provider during the global period for the first procedure.

Again, in this situation, the second provider can bill separately for the E/M service. No modifier is necessary.