Pediatric Coding Alert

And know whether the 2021 office/outpatient E/M changes will affect its use.

Modifier 24 is a useful — and potentially valuable — modifier that helps you obtain full reimbursement for your pediatrician when they conduct an evaluation and management (E/M) service during the global period of another service.

But as simple as that sounds, using modifier 24 is trickier than it looks. So here are three scenarios to help you understand when you can, and cannot, append it. And we’ll also take a look at whether use of the modifier has changed with the 2021 office/outpatient E/M guidelines.

How Modifier 24 Should Be Used

If you read the modifier’s descriptor closely, you’ll see three key details that you can turn into questions, which you can then apply to any scenario to see if you are using the modifier correctly.

1. Is the service an E/M?
2. Does the E/M occur during the global period of another service that has been performed by the same provider performing the E/M?
3. Is the E/M unrelated to that other service?

Basically stated, if your pediatrician performs a procedure that has a global package, then sees a patient for an E/M service at any point during the global period of that prior service, you should append modifier 24 to the unrelated E/M to separate both services, providing your documentation can justify that the E/M is not a part of the regular follow-up for the original procedure or is not related to the original procedure, such as being a complication from the procedure.

Still confused? Let’s see if these scenarios can provide some clarity.

Scenario 1: A 16-year-old established female patient comes into the office for a follow-up visit a week after your pediatrician removed a wart from the patient using cryosurgery, which had been previously coded with 17000 (Destruction [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [eg, actinic keratoses]; first lesion). While in the office, the patient tells your pediatrician that she has been experiencing stomach pain, and the physician diagnoses a urinary tract infection (UTI).

Can You Bill an E/M and Apply Modifier 24?

In this case, yes. Here’s why.

“Because you are still in the 10-day global period for the 17000 wart removal, you can bill and get reimbursed for an office/outpatient E/M visit in this case,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “But you will need to have the 24 modifier on the visit to indicate that it is not related to the global procedure. And you will have to list the UTI, and not the wart removal, as the diagnosis because this problem is in no way related to the wart,” Holle adds.

Scenario 2: Three days after your pediatrician performed a 2 cm laceration repair on an established 10-year old patient’s hand, coded with 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less), the patient returns with the wound area appearing swollen and red. There is also some discharge coming from the area of the sutures. The pediatrician diagnoses an infected laceration and treats the wound.

Can You Bill an E/M and Apply Modifier 24?

In this case, no. Here’s why.

Like the previous scenario, 12001 has a 10-day postoperative period. This time, however, “you would not be able to use modifier 24 and report an additional visit, because the visit is directly related to the original wound, and the visit is occurring during the global period of the laceration repair,” states Holle.

How Should This Encounter Be Coded?

In scenarios like this, there are two possibilities. On occasion, the procedure performed may end up requiring another procedure be performed due to complications. In this situation, you could bill a procedure code, but not the office/outpatient E/M, and the global period for the new procedure starts all over again.

Alternatively, you could use 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure) to indicate the patient is being treated for a condition related to the original service during the postoperative period of that service.

This code carries 0 relative value units (RVUs), and thus has no dollar value, because reimbursement for treating the infected laceration is incorporated in the postoperative period for 12001.

Remember this: As with all modifier use, documentation is vital. You will need to make sure that your physician is not treating complications from the condition or the surgery that the patient has undergone before, which often means recording a very different diagnosis for the E/M, and not the original one, before appending modifier 24.

Will the 2021 Office/Outpatient E/M Changes Affect Modifier 24 Use?

Even though the 2021 office/outpatient E/M guidelines no longer require that you count exams toward the E/M level, the “2021 E/M coding changes do not impact utilization of modifier 24 or 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] for that matter,” notes Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.