General Surgery Coding Alert

Find out if you really need a new diagnosis.

You don’t have to bundle every E/M service during a surgical global period. But just as surely, you can’t separately bill every E/M during global days.

What you need is a nuanced understanding of modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to learn when you can and can’t expect extra post-surgical E/M pay.

Read on to overcome modifier 24 claim challenges by busting four myths that will lead to denials and/or lost pay if you fall into their billing trap.

Myth #1: Modifier 24 Applies To Any Service Done In the Post-Op Period

You should only append modifier 24 to an appropriate E/M code when an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure. Modifier 24 tells the payer that the surgeon is seeing the patient for a new problem.

“The very definition of the modifier states it plainly: ‘unrelated evaluation and management service,’” points out Charlotte T. Tweed, RHIA, CPC, coding auditor, GME interim compliance manager, and privacy officer at Florida Hospital in Orlando.

Rule: You cannot bill separately for E/M services relating to the original surgery during the global period. The global surgical package includes routine postoperative care during the global period.

Additionally: Modifier 24 applies only to services your physician performs after the surgical procedure. If your physician performs an E/M service before a procedure or on the day of that procedure, you would possibly need a different modifier such as 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) or 57 (Decision for surgery). 

Myth #2: A Scheduled Office Visit Rules Out Use of Modifier 24

Just because a patient is scheduled for an office follow-up post-operative visit related to his surgery, you shouldn’t automatically assume that you can’t ever bill for a separate service using modifier 24.

Example: A patient has breast biopsy. When the patient returns a week later for suture removal, the surgeon tells him that the pathological examination revealed a malignant tumor. The surgeon then has a face-to-face discussion with the patient concerning new extended treatment for the tumor. The surgeon 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, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash. “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 care centers on something besides post-surgical care. 

Myth #3: You Can’t Use Modifier 24 For Postoperative Complications

CPT® guidelines don’t consider complications such as postoperative infections related to the initial surgery. That opens the possibility of billing for an E/M during the global period if the patient has a surgical complication.

For instance: If a patient has abdominal surgery and returns to your office with a postoperative wound infection along the suture line, you may be able to bill a separate E/M using modifier 24 to those payers following CPT® guidelines.  

Beware Medicare: Medicare and some private payers do not follow CPT® guidelines with respect to modifier 24 and will only pay for treatment of complications during a global period if the complication results in a return to the operating room.

Myth #4: There Must Be a New Diagnosis If You Use Modifier 24

While a different ICD-9 diagnostic code might indicate that the E/M service performed in a global period was unrelated to the surgery, you do not have to have different diagnoses to use modifier 24 and to receive payment for those services.

“It is not necessary that the two services have a different diagnosis, but documentation should clarify that you’re not billing an E/M for surgery-related work such as checking the wound, but instead, you’re billing for a service such as discussing results, prognosis and treatment options,” Bucknam says.

Caveat: “It is not mandatory to have a different diagnosis,” Tweed agrees. “However, that said, for some insurance companies, it is easier to get them to pay for an E/M completed during post op if the diagnosis is different.”