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General Surgery Coding Alert

Modifiers Key to Coding Physician Visits, Global Periods

Published on Fri Mar 01, 2002

A surgeon visits a patient in the hospital during the global period for that person's surgery and determines that a second procedure (unrelated to the first one) must be performed.
 
Although the doctor reports the unrelated procedure using the appropriate procedure code with modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) appended to it, there remains the question of how the surgeon codes the visit itself. 
 
Obtaining payment can be difficult, and the solution involves using the correct modifier on the appropriate E/M service.
 
Three modifiers may apply: -24 (Unrelated evaluation and management service by the same physician during a postoperative period), -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), or -57 (Decision for surgery).
 
Note: Medicare and many commercial carriers require that -57 be appended to the E/M if the surgery to be performed (and appended with -79) has a 90-day global period. Modifier -25 should be appended if the procedure has a 10- or 0-day global period.
 
"These three modifiers are supposed to be used to let the carrier know that there is something unusual about this situation, and they should take it out of their normal denial cycle and look at it," says Marcella Bucknam, CPC, a general surgery coding and reimbursement specialist and educator at Clarkson College in Omaha, Neb.
 
Carriers differ greatly on how such services should be reported: Some private carriers do not pay for modifier -24 claims, some pay for modifier -24 claims but not modifier -57 or modifier -25 claims, and some pay only when more than one modifier is reported.
 
If the physician appends modifier -24 to indicate the E/M visit occurred in the global period of an earlier procedure but should be paid because the patient's new problem is unrelated, some carriers may consider the E/M service included in the procedure that followed the initial visit.
 
If modifier -25 is appended to the E/M visit to indicate that it is significant and separately identifiable, some carriers may note that the service took place during the global period of the first procedure and reject the claim. Such carriers, which include both private payers and Medicare carriers such as Wisconsin Physicians Service (the Part B carrier in Illinois, Michigan, Minnesota and Wisconsin), may require physicians to append both modifiers -24 and -25 in such situations.
 
For example, the surgeon performs a left inguinal hernia repair (49507, Repair initial inguinal hernia, age 5 years or over; incarcerated or strangulated) on a 67-year-old man. The procedure has a 90-day global period. The patient's primary care physician readmits him three weeks later because of abdominal pain and consults the surgeon. That specialist diagnoses acute pain in the right lower quadrant of the patient's abdomen (789.03) with suspicion of appendicitis. A laparoscopic appendectomy 44970 (Laparoscopy, surgical, appendectomy) is performed later that day.
 
If only modifier -24 is appended, payment may be denied because 1) the carrier does not recognize procedure codes appended with -24 and/or 2) the carrier bundles the E/M service with the appendectomy.
 
If only modifier -57 is appended, payment may be denied because 1) the carrier does not recognize procedure codes appended with this modifier and/or 2) the carrier includes the E/M service in the global period of the hernia repair.
 
If the carrier denies for the second reason noted in either of the preceding denial scenarios, you may need to append both modifiers to the E/M code to avoid the turndown. In such cases, all the services performed during the day should be coded and modified as: 44970-79, 9924x-24-57.
 
Although she can see the logic of billing these services with both modifiers, Bucknam notes that "using any of these modifiers really just means pay this claim. So, in a way, putting two modifiers on is like saying pay it twice. But, in the end, it really depends on the insurance company."
 
Carriers that accept modifier -24 or modifier -57 alone are likely to have reimbursement quirks of their own, Bucknam says, noting that Nebraska's Part B carrier denies all claims on E/M services performed during the global period and pays them (when appropriate) only on appeal.
 
"With some carriers, it doesn't matter what modifier you attach. They just won't pay or will pay only on appeal. You need to be aware of that and have an automatic appeals process in place," she says.

Less Extensive Procedures

If the second procedure has a 0- or 10-day global period, the E/M service that prompted the need for the procedure should be appended with modifier -25, says Cynthia Thompson, CPC, a coding and reimbursement specialist with Gates Moore Healthcare Consultants in Atlanta.
 
For example, a female who had a laparoscopic cholecystectomy (47562) two weeks earlier sees the surgeon in the office during a follow-up visit and reports a lump in her breast (611.72) that was not present a month earlier. The physician then examines the patient, finds a palpable breast lump and aspirates a cyst. The cyst aspiration (19000, Puncture aspiration of cyst of breast), which has a 0-day global period, is billed with modifier -79 appended. Depending on carrier preference, modifier -25, -24, or both should be appended to the appropriate E/M code.
 
Although fewer denials are reported with -25 appended than with -57, the same problems may be encountered, she adds, noting that some carriers routinely do not pay for modifier -25 claims.
 
As with E/M services that prompt the need for more extensive surgeries, payment decisions are carrier-specific, and carriers may require modifier -24 or modifier -25 alone or the two procedures together. "If the E/M code isn't modified as per carrier requirements, it is less likely to be paid," Thompson says. "You have to find out the carrier's policy and obtain a written list of modifiers they do and don't accept." The list may also be useful when appealing subsequent denied claims, she adds.

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