Medical coding is an intricate process that demands specificity to ensure you receive rightful reimbursements against your rendered services. That’s why there are hundreds of CPT codes, and some descriptors have minor differences. Even then, there are modifiers to help you achieve coding accuracy and avoid overcoding and undercoding issues because care services are often tailored based on individual patient needs.
Unfortunately, many find it hard to determine which modifier should be appended in which scenario. One such modifier is 24. Thus, this guide will discuss modifier 24 in detail, including its practical examples and accurate usage guidelines. So, let’s get started!
Modifier 24 – Description
This modifier identifies an unrelated evaluation and management (E/M) service performed by the same healthcare provider during the postoperative global period, which is separately reimbursable.
For the unversed, the global period involves the entire timeframe related to the surgical process, including the day the surgery was performed. During this period, certain services are bundled into the surgery fee and are not separately reimbursable.
Modifier 24 – Examples
Discussed below are some of the practical scenarios where you may use modifier 24 to receive your rightful payment against the rendered services:
Evaluation of Shoulder Pain During the Hip Replacement Global Period
Assume a patient who underwent hip-replacement surgery and after 30 days came for a follow-up visit. During the encounter, the patient discusses experiencing shoulder pain. As a result, the healthcare provider documents the elements of an E/M service to evaluate and treat this new condition of the patient.
Thus, the evaluation and treatment of shoulder pain are unrelated to the previous procedure under both CMS and CPT guidelines, the physician will separately bill code 99213 and append it with modifier 24 to report a level 3, office, or other E/M encounter of an established patient for shoulder pain evaluation/management during the global period of hip replacement surgery.
Discussing Treatment Options After Breast Biopsy
Consider a scenario where a patient’s breast biopsy results show malignancy. As a result, the patient returns for a follow-up visit within the 10-day global period to discuss treatment options with the healthcare practitioner.
Thus, this discussion of treatment options is unrelated to the previously rendered breast biopsy under the CPT and CMS guidelines, so the provider may append the modifier 24 to ensure accurate coding and rightful reimbursements.
Evaluation of Postoperative Hip Replacement Complication
Let’s revisit the first scenario where the patient undergoes hip replacement surgery. What if instead of experiencing a new condition, the patient experiences complications with the previously performed surgery itself?
For instance, the patient experiences discharge, swelling, and pain at the hip replacement site and complains about the same to the physician during the 30-day follow-up visit. Thus, the clinician evaluates and treats the complications and documents it as an unrelated service to the hip replacement procedure by appending modifier 24.
Note: While appending modifier 24, remember that the global period is not the same for all CPT codes. Thus, verify the global period for a specific procedure to ensure coding accuracy and appropriate usage of modifiers. It may range from 0, 10, or 90 days, depending upon the procedure’s complexity.
Accurate Usage Guidelines for Modifier 24
The following guidelines for accurate and appropriate modifier 24 usage will help you steer clear of claim denials or any financial or legal repercussions:
- Rule # 1 is to ensure the E/M service the physician renders is unrelated to the initial surgery.
- Rule # 2 is that the unrelated E/M service must be rendered during the postoperative global period of the specific CPT.
- Rule # 3 emphasizes submitting detailed documentation to justify that the rendered E/M service was unrelated to the original procedure, yet medically necessary, and is eligible for separate reimbursement.
Use Modifier 24 If:
- During the postoperative period, the patient develops a new condition unrelated to the initial surgical procedure and requires an E/M service from the same physician.
- The patient has a chronic condition that worsened during the postoperative period.
- The rendered E/M service is related to a different anatomical site than the initially rendered procedure.
Avoid Using Modifier 24 If:
- The rendered E/M service during the postoperative global period is related to the original surgical procedure.
- The routine follow-up encounter in the global period against a CPT code is not eligible for this modifier due to package limitations.
- The E/M service during the postoperative period is provided by a different practitioner.
Summary
We strived to cover all aspects of modifier 24 to help you understand it better. Thus, here’s a quick recap of what we learned in this comprehensive guide.
We explained what this modifier indicates, what the global postoperative period means, and how this period varies for different procedures. Besides, we shared some practical scenarios where you may append 24, including evaluation of shoulder pain during the hip replacement global period, treatment options discussion following breast biopsy, and evaluation of postoperative hip replacement complication.
Moreover, we discussed its accurate usage guidelines. However, if you still find it challenging to determine whether you should append this modifier or any other modifier, you can outsource medical billing to professionals like MediBill MD.
Frequently Asked Questions
