Otolaryngology Coding Alert

Hint: not all postoperative services warrant using modifier 24.

Have you used modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) when coding for a patient who requires an evaluation and management (E/M) service after they had surgery? The good news is that you may have been on the right track if the E/M service fits the criteria for modifier 24 use.

However, there are several postoperative circumstances where using modifier 24 is inappropriate. For example, what if the E/M service was performed on the same day as the surgery? What if the surgery and E/M service were performed by different physicians? What if the E/M service is for a surgical complication?

Knowing when – and when not – to apply modifier 24 can feel like putting together a challenging puzzle. Here are the answers to some frequently asked questions to help you use modifier 24 appropriately.

What is Modifier 24?

Modifier 24 can be applied to all postoperative E/M services (99202-99499) as well as ophthalmological services 92002-92014 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate …), as long as these services are performed by the same clinician who completed the surgery and were completed during the global postoperative period.

It is important to note that, in the eyes of the payer, this does not mean the surgery and E/M service need to be performed by the same individual physician or qualified healthcare professional (QHP). Payers define the “same physician” as any physicians or QHP who belong to the same practice group and have the same specialty. This is because the global period is assigned to the group practice and specialty, not just the specific surgeon who performed the surgery.

When is Modifier 24 Applicable?

Timing is one of the biggest keys to appropriate use of modifier 24. If the patient received unrelated E/M services on the day of their surgery, you should not use modifier 24. Instead, you should use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), which is meant for same-day E/M services that are not related to the other procedure or service the patient received that day.

Modifier 24 is only appropriate during the procedure’s global postoperative period. Depending on whether the procedure is designated as minor or major, the global postoperative period may be 10 days or 90 days. If the global postoperative period has passed, modifier 24 is no longer applicable.

What is Already Covered by the Surgery Code?

That depends on the payer. One of the most difficult aspects that coders face when applying modifier 24 is understanding how payer rules affect whether a postoperative E/M service should be coded with modifier 24, and when it is already covered by the global surgery package.

The CPT^® code book and guidance from the Centers for Medicare & Medicaid Services (CMS) agree that global surgical packages include routine and related postoperative care, but they differ on the definition of “related.” This means the first step to applying modifier 24 correctly is to determine whether the payer uses CMS guidelines or guidance from the AMA.

CMS guidelines stipulate that modifier 24 should be applied when a patient visits the same physician or QHP who performed their surgery for the treatment of a problem unrelated to the surgery within the global postoperative period. So, under CMS guidance, modifier 24 should not be used on routine postoperative care including management of any complication that does not require another visit to the operating room, but it should be used on E/M services that treat the same underlying condition that was addressed by the surgical procedure. For example, it would be appropriate to use modifier 24 on a patient who receives medication adjustments for a condition following surgery for that condition.

AMA guidance and CPT^® guidelines differ from CMS on including surgical complications in the global surgical package. According to CPT^® and AMA guidelines, wound care, pain management, and treating surgical complications are all separately billable E/M services. Additionally, unlike CMS guidance, AMA guidance stipulates that modifier 24 should be used when the patient visits the same physician or qualified health care professional for the treatment of a new problem during the global postoperative period.

What are Some Examples of Correct Use of Modifier 24?

Let’s revisit the example of a patient who receives medication adjustment within the global postoperative period following surgery. Presuming the medication adjustment and surgery were both performed by the same physician or QHP during the global postoperative period as defined by the payer, and that the payer follows CMS guidelines, this is an appropriate use case for modifier 24 because:

• The E/M service is not part of routine postoperative care.
• The E/M service is intended to manage the same underlying condition as the surgery.

Now let’s examine a scenario where the payer follows AMA guidance. A patient visits the same physician or QHP who completed their surgery within the global postoperative period. In this case, using modifier 24 would be appropriate if the patient presents with:

• An infection at the incision site
• Pain in the affected ear

Had this been a payer that followed CMS rules, however, CMS would not allow the E/M-24 because treatment of the infection or postoperative pain are included in the global period and not separately coded or billed.

Key Takeaways on Modifier 24

When in doubt, the biggest questions to ask yourself about modifier 24 revolve around timing and payer rules. If a patient receives E/M services from the same physician or QHP (as defined by the payer) who performed their surgery, and the global postoperative period has not yet expired, it may be appropriate to use modifier 24. By referencing payer rules, you can determine whether the visit warrants use of modifier 24, if the E/M services are already covered in the global surgical package, or if a different code is necessary.

Michelle Falci, BA, M Falci Communications, LLC