Urology Coding Alert

Remember: It’s all about ‘unrelated.’

Appending modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to a claim can potentially help a physician gain entitled additional reimbursement for services within a global period. But do you know the ins and outs of when modifier 24 is allowed? Read on for expert advice you can put to use today.

Tip 1: Get in the Correct Code Family

You can append modifier 24 to any E/M code from 99201-99499.

Example: A patient comes to the office a few days after a 90-day global procedure for the biopsy results/report. The doctor talks to the patient for 15 minutes about results and different types of new treatments required. You should report the appropriate office visit code, such as 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 ...), based on the time your urologist spent reviewing the results face to face with the patient. Since this visit does not constitute a true postoperative follow up examination or care of a recent surgical wound but rather a visit to review the biopsy results with the patient, you can report the E/M service with modifier 24.

Tip 2: Verify the Same Physician Is Involved

Before considering modifier 24, ensure that the same physician who performed the original surgical procedure or one of his associates sees the patient during the postoperative period for an E/M service unrelated to the postoperative surgical care.

In fact, if the patient reports foranyunrelated E/M that occurs during a postop global period — including hospital visits, office visits, etc. — you may append modifier 24, according to Celia  Forde,  CPC,  CPCH, coding specialist for Florida’s Centra Care, in the Orlando area.

Tip 3: Look for ‘Unrelated’ Service

Only append modifier 24 to an appropriate E/M code when the physician renders the E/M service during a 10- or 90-day postoperative global period for reasons unrelated to the patient’s surgery.

You cannot bill separately for E/M-related services relating to the original surgery during the global period. A surgical complication or infection is considered part of the surgery package. When you append modifier 24, you are telling the payer that the surgeon is seeing the patient for a problem unrelated to surgery. Therefore, the medical record must support that the E/M visit was unrelated to the postoperative care, and the diagnosis should clearly indicate the reason for the unrelated postoperative encounter.

Example: A patient has a biopsy of a penile lesion. When the patient returns a week later for suture removal, he is notified that the pathological examination revealed a malignant tumor. The urologist has a face-to-face discussion with the patient concerning new extended treatment for the tumor. The urologist bills an E/M office visit based on the time he spent with the patient counseling him on the necessary therapy and coordinating his further treatment.

In this case, you should use modifier 24 to describe an E/M service unrelated to the surgery (only related to the disease process), says Marcella Bucknam, CPC, CCS-P,  CPC-H,  CCS,  CPC-P,  COBGC,  CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. “CPT® would always allow this but, even Medicare states that care directed at the underlying disease process may be separately billable and paid in the global period.”

Modifier 24 only applies to services your physician performs after the surgical procedure. If the physician performs an E/M service on the same day as another procedure, you could look to 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) for minor procedures or modifier 57 (Decision for surgery) for major procedures. Modifier 57 also applies to E/M codes resulting in a decision for surgery performed the day before the major procedure.

Some third-party payers will consider services provided for some complications. Touch base with them for further information on this coding before submitting theclaim.

Tip 4: Consider 24 Even for Scheduled Visits

Let the example above teach another lesson: seeing a patient during a scheduled office visit does not negate the possibility of reporting modifier 24.

Even though the visit described in Tip 3 was scheduled as a follow-up post-operative visit, you can use modifier 24 to ensure payment when the above clinical circumstances occur. “People put too much emphasis on how a visit was scheduled,” Bucknam says. “No one typically sees your clinic schedule. It’s the specific documentation of the visit that counts. Additionally, no one would think that they shouldn’t bill separately if the patient came in for follow up and also had a broken finger that needed treatment! It’s the same thing, just more subtle.”

The one cautionary issue around the schedule is if your electronic record is connected to the schedule and automatically adds edits that need to be reviewed prior to claim submission, adds Suzan Hauptman, MPM, CPC, CEMC, CEDC AAPC fellow, senior principal of ACE Med Group in Pittsburgh.