Ophthalmology and Optometry Coding Alert

Question: Can you use modifier 24 when the surgery and the E/M with 24 have the same diagnosis?

Answer: Yes. When appending modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to an unrelated inpatient visit within the global period of a surgery, be sure to report the appropriate diagnosis code(s) based on the documentation. Reporting the same diagnosis code for both the procedure that triggered the global period and for the unrelated visit is OK and the appropriate choice if that’s what the documentation supports.

While coding based on what the documentation supports, rather than choosing codes just to get paid, is always the right thing to do, in some cases, the payer may specify that using the same diagnosis will trigger a denial or may require you to submit supporting documentation. Check your individual payer policy to be sure.

Inpatient: For instance, MACs “do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery,” says Medicare Claims Processing Manual (MCPM), Chapter 12, Manual 30.6.6 (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf).

Outpatient/office: For non-inpatient services, the MCPM states, “A/B MACs (B) pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT^® codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT^® modifier ‘-24,’ and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure.”

The MCPM also states, “Services submitted with the ‘-24’ modifier must be sufficiently documented to establish that the visit was unrelated to the surgery. A diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable documentation.” That quote suggests the different diagnosis isn’t required, but you’ll need to plan to support your choice if the diagnoses are related. 

MAC: You also may find guidance from individual MACs. For example, Novitas has a modifier 24 article, last reviewed in April, which states that modifier 24 would be appropriate when “Documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care.” The same article adds, “The same diagnosis as the original procedure could be used for the new E/M if the problem occurs at a different anatomical site.” You can find the article by starting at www.novitas-solutions.com/webcenter/portal/MedicareJH/Medicare_JH and searching for “modifier 24 article.”