Orthopedic Coding Alert
Use Modifier 24, Tighten Up Unrelated Postop E/M Claims
If the service is related to the surgery, it’s not separately codeable. A patient is in the postoperative global period for a recent surgery. The patient reports to the orthopedist for an office/ outpatient evaluation and management (E/M) service during the postop period — but the problem is unrelated to any postop treatment included in the surgical package. What do you do? That’s what we asked Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington; and Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. Their answer was the same: Use modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to separate the E/M from the surgical package. Here’s what else they had to say on coding E/Ms with modifier 24. Q: In which situations would a coder need to use modifier 24 on an E/M service? A: Hauptman “Coders would need to use the 24 modifier when a patient is seen during a postoperative period for a service unrelated to the surgery.” A: Bucknam “Anytime an E/M service unrelated to the surgery itself occurs during the global period of a procedure modifier 24 would be both appropriate and required. One of the most common uses is when a patient has a bilateral condition that requires surgery on one side and then during the global period an evaluation of the contralateral side is done. Modifier 24 would be required for this. This might happen for a patient with bilateral carpel tunnel syndrome. If one side is worse than the other the surgery on the worse side might happen first with evaluation of the other wrist during the global period. “Of course, another example would include two unrelated traumas with evaluation of the second trauma in the global period of the first procedure. “Keep in mind that this only applies to the surgeon. If a provider in another specialty provides an E/M service, modifier 24 is not needed. For this reason modifier 24 is not used that commonly. Surgeons are specialists so it’s somewhat unusual for a separate unrelated evaluation to happen by the surgeon during the global period.” Q: Could you provide an example in which the physician provides a modifier 24 E/M for a patient? A: Bucknam “A patient has a diagnosis of bilateral carpel tunnel syndrome, right worse than left. The decision is made to perform carpel tunnel release on the right arm.” “At the six-week postop follow-up visit, the patient also complains that the extra use of her left arm during the recovery has increased her left wrist pain significantly. The surgeon performs an examination of her left arm (detailed exam and moderate decision making) and concludes that surgery is appropriate for that arm as well (99214-24).” Since you were in the postop period of the CT release (64721 [Neuroplasty and/or transposition; median nerve at carpal tunnel]) and the problem the provider treats during the E/M is unrelated to that specific CT release, you can report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …) with modifier 24 appended, Bucknam says. Q: Is it possible for a service to start out as postop care, and then turn into an E/M-24? A: Hauptman “Absolutely! If the physician goes into the patient’s room (inpatient) and evaluates how the wound is doing from the surgery, and the patient complains of something new, this could be ‘carved out’ as a billable service with the new diagnosis. The diagnosis related to the surgery would not be reported on a claim with a -24 modifier.” A: Bucknam “Yes. It would not be unusual for the visit with separate elements to start out as a regular surgical follow-up. In fact, that might be the most frequent time modifier 24 would be appropriate.”
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