Pain Management Coding Alert

Question: A patient developed a post-op infection during the global period of a surgery and returned to the operating room (OR). Can we bill the hospital visit evaluation and management (E/M) visit with a modifier 24?

Connecticut Subscriber

Answer: You can only append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to an E/M service when the physician renders an E/M during the patient’s global surgery period that is not related to the patient’s surgery. If the infection is related to the surgery, the MAC considers it part of the original procedure.

However, if the need is there to return to the operating room, the physician could bill the service with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

When you report modifier 24, the E/M service must meet the following requirements:

• The E/M service occurs during the postoperative period of another procedure.
• The current E/M service is unrelated to the previous procedure.
• The same physician (or tax ID or same group and specialty) who performed the previous procedure provides the E/M.
• The patient’s diagnosis documented must meet medical necessity for the visit.
• The documentation should clearly illustrate how this visit is not related to the original surgery.

According to the Medicare Administrative Contractor (MAC) Noridian, you should never use modifier 24 in the following situations:

• When the E/M is for a surgical complication or injection.
• When documenting treatment of an infection of a wound — consider this part of post-operative care.
• When the patient is admitted to a skilled nursing facility for a condition that is related to the surgery.
• When the E/M is not clearly shown to be unrelated to the surgery in the medical record documentation.
• Outside of the post-op period of a procedure or on the same day as the procedure.