Saturday, November 27, 2010

Usage of Modifier 24 with example

Modifier 24 - Unrelated evaluation and management by the same physician during a postoperative period

The following rules apply:

    * Modifier 24 is applied to only two possible code sets: evaluation and management (E/M) services (99201-99499) or general ophthalmological services (92002-92014), which are eye examination codes.

    * Modifier 24 is not valid with surgical procedures, labs, x-rays, or supply codes.

    * The new E/M service or eye exam usually involves a different diagnosis, but not always. For example, the same diagnosis as the original procedure could be used for the new E/M if the problem occurs at a different anatomical site.

    * Modifier 24 is not used to report exams performed for routine postoperative care.

    * Modifier 24 is an information modifier.

Instructions

    This modifier can be used to indicate that an E/M service or eye exam, which falls within the global period of a major or minor surgery and is performed by a surgeon, is unrelated to the surgery.
    This modifier can only be submitted with E/M and eye exam codes.
    When this modifier is submitted, supporting documentation of an unrelated ICD-9 code and/or additional documentation may be requested to support that the E/M service is unrelated to the surgery.
    If the ICD-10 code for the E/M service clearly supports that the visit was unrelated to the surgery, there is no need to submit additional documentation.

Special Instruction for Ophthalmologists

    If the exam and prior surgery were performed on different eyes, this information needs to be indicated in the appropriate field. HCPCS modifiers RT and LT may not be submitted with eye exam codes.

Correct Use

    Do not use this modifier 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.
    Do not use this modifier when the patient is admitted to a skilled nursing facility for a condition that is related to the surgery.
    Do not use this modifier when the E/M is not clearly shown to be unrelated to the surgery in the medical record documentation.
    Do not use this modifier outside of the post-op period of a procedure or on the same day as the procedure.


* Additional documentation required with this modifier is: sufficient documentation to establish that the visit was unrelated to the surgery; an ICD-9 diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery.

* The documentation to establish the visit was unrelated to the surgery must appear in the appropriate documentation record for electronic claims or on an attachment to the CMS-1500 claim form for paper claims.

* Failure to submit this documentation appropriately may result in services denied as part of the cost of the surgical procedure.

Coding Claim Example

The patient comes in for a lesion removal, which has 10 postoperative global days. Four days later, patient comes in for a new condition of upper respiratory infection (URI). Since the URI is a new, unrelated condition during the postoperative period, modifier 24 is appended to the E/M code. If modifier 24 is not appended to the E/M code, it will be denied as included in the global package of the surgery. The second diagnosis code must be unrelated to the lesion removal to allow for separate payment. Even though there are two separate unrelated diagnosis codes on the claim, the new diagnosis alone will not pay the claim.



Example

Dr. Smith sees an established patient in his office who had a bike accident. Dr. Smith performs an intermediate repair for a 4.0cm wound on the patient’s forehead. The repair has a 10-day global period. Three days later, the patient sees Dr. Smith complaining about sinus trouble. Dr. Smith performs a problem focused exam and diagnoses the patient with a sinus infection. He writes a prescription and codes the visit as a 99212-24.


Modifier 24 Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period 

• Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the postoperative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the postoperative care of the procedure

Usage of Modifier 24

Critical Care

Critical care services furnished during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure
and may be paid separately under the following circumstances.

Pre-operative and post-operative critical care may be paid in addition to a global fee if:

• The patient is critically ill and requires the constant attendance of the physician; and

• The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed.

Such patients are potentially unstable or have conditions that could pose a significant threat to life or risk of prolonged impairment.

In order for these services to be paid, two reporting requirements must be met:

• CPT codes 99291/99292 and modifier “-25” for pre-operative care or “-24” for post-operative care must be used; and


The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the CPT modifier 24 to the appropriate level of E/M service.

**  Additional documentation required with this modifier is: sufficient documentation to establish that the visit was unrelated to the surgery; an ICD-9 diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery.

** The documentation to establish the visit was unrelated to the surgery must appear in the appropriate documentation record for electronic claims or on an attachment to the CMS-1500 claim form for paper claims.

** Failure to submit this documentation appropriately may result in services denied as part of the cost of the surgical procedure.

• Use modifiers “-24” (Unrelated E/M service by the same physician during a post-operative period) and “-25” when a significant, separately identifiable E/M service on the day of a procedure falls within the post-operative period of another unrelated, procedure.

During Postpartum Stage:

UnitedHealthcare Community Plan will reimburse non-OB related office E/M services rendered during the postpartum care when submitted with modifier 24. Please see UnitedHealthcare Community Plan's "Global Days Policy" for additional information.


The physician may need to indicate that an E&M service was performed during a postoperative period for a reason(s) unrelated to the original procedure.

This circumstance may be reported by adding the modifier 24 to the appropriate level of E&M service. For example:

DOS: January 10, 2014
Diagnosis code: 171.2
Procedure code: 11606
Post-Operative period for 11606: 10 days
DOS: January 15, 2014
Diagnosis code: 692.0
Procedure code: 99212-24



In order for the E&M service to be payable in the post-operative period with the 24 modifier, the diagnosis code supporting the E&M service must be different from the diagnosis code reported for the previously performed surgery.

Modifier 24 should not be used for the medical management of a patient by the surgeon following surgery.


Critical Care

Critical care services furnished during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances.

Pre-operative and post-operative critical care may be paid in addition to a global fee if:

• The patient is critically ill and requires the constant attendance of the physician; and

• The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed. Such patients are potentially unstable or have conditions that could pose a significant threat to life or risk of prolonged impairment.

In order for these services to be paid, two reporting requirements must be met:

• CPT codes 99291/99292 and modifier “-25” for pre-operative care or “-24” for post-operative care  must be used; and

• Documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted. An ICD-10 code for a disease or separate injury which clearly indicates that the critical care was unrelated to the surgery is acceptable documentation.


Modifier 24 is used only with E&M services. 

Services submitted with Modifier 24 must be sufficiently documented in the member medical record to establish that the visit was unrelated to the condition that initially required the surgery.


The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the CPT modifier 24 to the appropriate level of E/M service.

** Additional documentation required with this modifier is: sufficient documentation to establish that the visit was unrelated to the surgery; an ICD-9 diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery.

** The documentation to establish the visit was unrelated to the surgery must appear in the appropriate documentation record for electronic claims or on an attachment to the CMS-1500 claim form for paper claims.

** Failure to submit this documentation appropriately may result in services denied as part of the cost of the surgical procedure.


Documentation is required when billing modifier 24

Based on widespread probes of office evaluation and management (E/M) services, First Coast has discovered that the 24 modifier for E/M services, when billing within a global surgery period, has been billed incorrectly at least 60 percent of the time. Clinical review of documentation demonstrates that modifier 24 was either not supported for the encounter, or was improperly applied (i.e., a different modifier should have been submitted).

To address this widespread improper billing, First Coast implemented a pre-payment edit on April 16, 2012, applicable to office visit E/M claims (Current Procedural Terminology® codes 99201-99205 and 99212-99215) billed with the 24 modifier.

Claims

For claims containing modifier 24 received on or after April 16, 2012, First Coast began requesting supporting documentation that justifies the use of the 24 modifier. Providers must respond within the specified timeframe included in the development letter. Failure to submit the documentation timely may result in a claim denial.

Reopenings

Also effective April 16, 2012, First Coast no longer accepts:

• Telephone requests via the interactive voice response or a customer service representative to add or change the 24 modifier on a previously denied claim.

• Written or fax requests to add or change the 24 modifier without supporting documentation. The provider will be sent a written notification that their request could not be completed.

Modifier 24 - Frequently asked questions

Q. Does modifier 24 only apply to Medicare?

A. Modifier 24 is a Current Procedural Terminology modifier, which is universally recognized by most insurance companies. Information found on the website is relative only to Medicare's guidelines. For more information on the use of modifier 24 by other insurance companies, please contact the appropriate company for their guidelines and policies on usage


Q. Is a pre-operative visit the week before a surgery considered within the "global period?"

A. No. For major surgeries, a pre-operative visit on the day of or the day before the surgery would be included within the global period. If the decision for a major surgery was made during an evaluation and management (E/M) visit, you can bill the E/M with a modifier 57, indicating the decision for surgery. For minor surgeries, there are no pre-operative days in the global period and the modifier 57 would not be applicable.

Q For follow-up visits, is it better to bill a post-operative visit E/M code without modifier 24, to bill CPT code 99024 (post-operative follow-up visit), or to not bill the visit at all?

A. If the service is being provided for post-operative care, it is not necessary to bill the visit unless you are seeking a denial for a secondary insurance.

Current Procedural Terminology code 99024 is a bundled code within Medicare, meaning payment is always bundled into the payment of other services; you would not bill this code to Medicare.


Q. If a physician's assistant (PA) gathers initial information and the physician performs the examination and medical decision making, but the PA dictates the office note, do both the physician and PA need to sign the record for proper documentation?

A. This depends on whether the service is a split/shared visit or if the visit is considered "incident to."

When an evaluation and management (E/M) service is a split/shared encounter between a physician and a non-physician practitioner (NPP), the service is considered to have been performed incident to the physician if the requirements for "incident to" are met and the patient is an established patient. If "incident to" requirements are not met for the split/shared E/M service, the service must be billed under the NPP's national provider identifier (NPI).

A split/shared E/M visit is defined by Medicare as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, examination or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.

If the physician's signature is the only signature on the visit, Medicare assumes that he/she is indicating they personally performed the visit. Notes recorded in the patient's medical records by another provider are considered relevant documentation of the encounter. Documentation may be dictated and typed or hand-written, or computer-generated and typed or handwritten. Documentation must be dated and include a legible signature or identity.

Q. For a patient who has had a surgery performed elsewhere (e.g., out of state), can the patient be seen for post-op care by a local physician and can the local physician bill for an E/M visit?

A. As long as the service is medically necessary and the component work has been provided, a separate evaluation and management (E/M) service could be billed without modifier 24, since the physician seeing the patient is not the same one who performed the surgery.

However, there are occasions when more than one physician provides services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish follow-up care. Payment for the postoperative, post-discharge care is split between two or more physicians where the physicians agree on the transfer of care.

When more than one physician furnishes services included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services.

Where physicians agree on the transfer of care during the global period, the following modifiers are used:

• Modifier 54 is for surgical care only; or
• Modifier 55 is for postoperative management only.

Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case


Q. For care performed by the same physician within the hospital after a surgical procedure has been provided, can the visits be billed separately?

A. Any visits provided during a hospitalization with a surgery (except critical care and emergency room visits) by the physician who performed the surgery would not be separately billable, as they would be considered part of the global care (including post-op) of the patient. Other providers involved can bill for appropriate visits.

However, after the hospitalization, if the patient sees the same physician outside the hospital and during the global period, modifier 24 rules would apply to any potentially separately billable visits



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