Orthopedic Coding Alert

To avoid denials for an E/M service on the same day as (or during the global period of) a procedure, try this foolproof method for choosing between 24, 25, and 57. Subscriber Anita Odum, coding specialist for Blue Ridge Orthopedic and Sports Medicine in Abingdon, Va.,e-mailed the Orthopedic Coding Alert editor and asked: "Our doctor saw a patient for an E/M service in the office and is going to perform a [related, major] surgery that evening or the next day. What modifier should I attach to the E/M service?"

Ask yourself these questions to eliminate the bad choices and select the modifier that will provide the carrier with an accurate picture of the E/M service.

Answer: No.

In the subscriber's situation, the E/M service happens prior to the surgery. Therefore, you would not choose modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

Rationale: When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 to the appropriate E/M code. Modifier 24 tells the payer that the surgeon is seeing the patient for a new problem. Therefore, the plan should not include the E/M service in the previous procedure's global surgical package.

Rule: You cannot bill separately for E/M-related services during the global period, says Maggie M. Mac,CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla.

The global surgical package includes routine postoperative care during the global period.

Answer: Major.

Because the surgery was a major service, then you should strike off modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) as an option.

Rationale: If the surgeon provides a significant,separately identifiable E/M service on the same date as a minor procedure, including those with zero-day, 10-day, or "XXX" global periods, you should append modifier 25 to the E/M code, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

Answer: Yes.

In the subscriber scenario, the surgery is "major" and "related" to the E/M service the physician performs the day of or the day prior to the surgery. Therefore, you should append modifier 57 (Decision for surgery) to your E/M service (such as 99214, Office or other outpatient visit ...) to indicate that this E/M service led to the decision for surgery.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M service into the global surgical package, leading to a loss in reimbursement.Without the modifier, the visit will appear to be the preoperative visit that the global surgical package includes.

For instance, suppose your orthopedist performs 27245 (Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage), which has a 90-day global period. If you failed to apply modifier 57 to the E/M code (such as 99214), you would receive payment only for 27245, and not 99214,costing you more than $90.

When you correct your claim by appending modifier 57, however, you should be paid for the visit. Medicare's 2009 Physician Fee Schedule, which can be used as a benchmark for private payers' rates, assigns 2.56 relative value units (RVUs) to 99214 and pays the code nationally at $92.33.

Tip: Relax; if you haven't been using the correct E/M appendage, all is not lost. Many Medicare carriers have a dedicated review line that you can call to add the missing modifier, and payment is usually processed between 10 and 14 days.