Urology Coding Alert

See what role, if any, 2021 office/outpatient E/M changes may play in your coding.

Reporting modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) accurately and compliantly requires a combination of knowledge of the guidelines and a strict attention to detail. However, often the best way to learn the ins and outs of modifier reporting is through real world practical application scenarios.

Read on for a breakdown of modifier 24 use and how you should apply it to your E/M coding.

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 provider 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.

Find Out If Modifier 24 During 10 Day Global Period Works

Scenario 1: An established male patient comes into the office for a follow-up visit a week after your urologist performed a biopsy of a deep skin penile lesion, which had been previously coded with 54105 (Biopsy of penis; deep structures). While in the office, the patient tells your urologist that he has been experiencing a burning sensation upon urination, and the physician diagnoses a urinary tract infection (UTI) unrelated to the previous biopsy procedure.

In this case, yes. Here’s why.

“Because you are still in the 10-day global period for the 54105 penis biopsy, 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. However, you will still need to append modifier 24 to the visit to indicate that it is not related to the global procedure. You will also list the UTI, and not penile lesion, as the diagnosis because this problem is in no way related to the lesion.

If Visit Isn’t Related to Surgery, Do This

Scenario 2: Three days after your provider performed the same deep skin penile lesion biopsy, coded as 54105, the patient returns with the wound area appearing swollen and red. The physician diagnoses an infected surgical site and treats the wound.

In this case, no. Here’s why.

This surgery was for a Medicare Part B patient. Unlike instructions provided in CPT^® code book (page 84), Medicare does not cover any post-operative complications treatment unless it requires a return to the OR. Like the previous scenario, you’re still working with a 10-day postoperative period for 54105. This time, however, “you would not be able to use modifier 24 and report an additional visit because the visit is for complications related to the original biopsy — and the visit is occurring during the global period of the related procedure,” states Holle.

How Should This Encounter Be Coded?

You will report 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 and track the patient as 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 site is incorporated in the postoperative period for 54105 for a Medicare Part B patient.

Do 2021 E/M Changes Affect Modifier 24 Use? Find Out

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.

The bottom line: “The documentation should support that the service rendered is unrelated to the initial service that has created the post-operative global period, thus the need for the modifier 24. That means providers should try to limit the scope of the second visit to only the new problem.,” says Walaszek. If they simultaneously address both issues at the second visit, the encounter should be coded based on medical decision making (MDM) or time related to treating the unrelated problem. Any MDM or time treating normal post-operative care should not be used for MDM or time consideration.

This means making sure you code the diagnosis for the new problem and link it to the E/M, and not add the diagnosis for the previous problem as a secondary diagnosis to the E/M when appropriate.