Wiki modifier 24 and Medicare

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solocoder

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Since Medicare updated their definition for modifier 24, does this mean we cannot bill an e/m service when a patient comes in for a post op visit, but also wants the doctor to address a new, completely unrelated problem? It doesn't seem to mention that scenario. I recently had a claim denied on appeal that was one of these situations. They included it in the global.
per WPS:

Use on an unrelated E/M service beginning the day after a procedure, when the E/M is performed by the same physician during the 10 or 90 day post-operative period.
Use modifier 24 on the E/M if documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care
 
What "update" are you referring to?

Here is WPS's Medicare fact sheet.

https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-24

So, you cannot bill an E/M for a postop visit if it's related to the procedure that started the postop.

You CAN as long as it's for a separate problem and the medical notes CLEARLY indicate that there was a separate problem.

Their sheet states... "Do not use unless the medical record documentation clearly indicates the E/M was unrelated to the surgery. "

also

Use on an unrelated E/M service beginning the day after a procedure, when the E/M is performed by the same physician* during the 10 or 90 day post-operative period.

If this IS the case, then make sure you highlight in the notes the appropriate separate problem and re-appeal.

Also remember that if any new problem required a minor surgical procedure (0 or 10 postop days) the E/M is included and can't be billed unless separate and identifiable.
 
It's the part about "e/m unrelated to the surgery" that I am stuck on. If the first line of the note reads "patient presents for post op visit" -related. New problem addressed - unrelated. What about when it is both?
 
You certainly can bill for the unrelated E/M.

You have to re-appeal and highlight the area of the claim pertinent to the unrelated problem and make sure you point this out in your appeal cover letter.

Included verbiage something along the line of...

"The E/M submitted is for a NEW PROBLEM unrelated to the service that initiated the postop period"...


Remember, that the claim reviewers examine hundreds of appeals a day. They read the first line of the chart note and stopped. They didn't keep reading.

You have to GRAB THEIR ATTENTION in your appeal cover letter. Make it EASY for them to discern the separate problem. Highlight only the stuff related to the separate problem.

Or teach your Doc to document with the words NEW PROBLEM or NEW CHIEF COMPLAINT or something like that so it's easy to distinguish.


One last question... did you bill any procedures or surgical services for the new and unrelated problem? Remember that the E/M is included in minor surgical services (codes with 0 or 10 postop days)
 
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