Orthopedic Coding Alert

Recoup money for E/Ms unrelated to postop with this modifier.

How to use modifier 24 is one of those questions that many coders don't ask, because they don't get the chance to use it very often. If you don't know proper application of modifier 24, however, you could be in hot water - especially in an orthopedic practice, where managing patients' postoperative periods could be a full-time job.

Why? When the provider performs a separate evaluation and management (E/M) service during the global period of a surgery, you'll need to use modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to ensure proper coding.

Check out this FAQ on modifier 24 to get all the info you'll need to submit successful postop E/M claims.

Q: Do coders need modifier 24 for any unrelated E/M that occurs during the postop global period?

A: Yes, says Leslie Johnson, CPC, coding consultant in Flagler Beach, Florida. "There are a lot of [unrelated] events that can happen, causing a patient to return to their physician during the global period.

"The only way to tell the insurance company that the E/M is not for any related follow-up care for a procedure with a global period is to put modifier 24 onto the E/M," continues Johnson.

Q: In which situations would a coder need to use modifier 24 on an E/M service?

A: Sometimes you need to tell a payer that an encounter is for something other than a follow-up for a procedure, but the E/M occurred within the surgery's global period. "Modifier 24 will be the modifier to do that," explains Johnson.

More info: Modifier 24 is appended to an E/M service (never to a procedure) to indicate that an unrelated E/M service was provided by the same physician during a postoperative period, explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Other "same-specialty physicians" are included in the definition of "same physician," continues Falbo. "That is, if a surgeon is covering postop patients for her partner, the covering surgeon is considered the same physician and does not bill for it. Remember, modifier 24 is used for an unrelated E/M service."

Q: What are some situations in which you'd use modifier 24?

A: Johnson offers this pair of examples:

"A patient had a right total hip replacement and during the postoperative period, the patient fell, injuring his right ankle. The physician does an exam of the right hip to make sure it's OK, but also does a history and an exam of the left ankle.

"To bill for the encounter, modifier 24 must be put onto the E/M procedure code to show the insurance company that the exam for the ankle was separately distinct from any exam related to the procedure that's within the global period. In order to bill for the appropriate level of service, the documentation must show that there is a separate history and/or exam and MDM [medical decision making] for the ankle."

Johnson offers up another scenario: "A patient has a permanent right hallux toenail removal. The postop period for 11750 [Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal] is 10 days. Seven days later, the patient returns complaining of his left hallux toenail being painful. The physician does a history/exam and MDM, and decides the left toe is infected and gives the patient antibiotics, instructing him to return in another week."

To report this encounter, the physician's documentation should show that a history, exam, and/or MDM was separately distinct from the procedure that caused the global period (11750). So, let's say that the patient in the 11750 scenario was established, and the operative notes indicated a level 3 E/M service.

You'd report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity ...) with modifier 24 appended for this unrelated E/M within the global period of another procedure.

Q: Is it possible for a service to start out as postop care, and then turn into an E/M-24?

A: Yes, says Johnson, who provides this example:

"A patient is following up with his surgeon after an ORIF [open reduction internal fixation] of the right wrist. During the exam, the patient mentions that his knee has been bothering him the past week.

"After ordering x-rays, the provider determines that the patient is suffering from osteoarthritis of the knee," continues Johnson. "During discussion, the patient opts for conservative care and receives a prescription for NSAIDs [nonsteroidal anti-inflammatory drugs] and is told to return in one to two weeks for a follow-up exam." Notes for the knee E/M, separate from the follow-up care for the ORIF surgery, indicate an expanded problem focused history and exam.

"The issue for the knee isn't related to the previous fracture of the wrist, but it's within the global period of the ORIF, so modifier 24 is placed onto the appropriate level of E/M," says Johnson.

For the unrelated postop E/M, you'd report 99212 (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 problem focused history; A problem focused examination; Straightforward medical decision making ...) with modifier 24 appended. Don't forget to append M17.11 (Unilateral primary osteoarthritis, right knee) to 99212 to show that the E/M had nothing to do with the patient's post-ORIF care.