General Surgery Coding Alert

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. [...]