Claim Payment Policy

---

Title:

Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period

Policy #:

03.00.15f

---

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified. In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service. For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the Company's reporting requirements for Modifier 24: Unrelated evaluation and management service by the same physician during a postoperative period. For additional information regarding the reporting of services performed by the same physician, refer to the Cross References section in this policy.

Description

A physician may need to indicate that an evaluation and management (E&M) service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by appending Modifier 24 to the appropriate level of E&M service. Certain preoperative visits and postoperative services are typically included in the global surgical fee for a surgical procedure. The services included in the global surgical fee may be furnished in any setting (eg, hospital, ASC, physician's office). The global surgical fee includes the following: Preoperative visits that occur after the decision to operate is made The preoperative period begins the day prior to the day of surgery for major procedures, and the day of surgery for minor procedures. Intraoperative services, which include the usual and necessary services typically carried out during the surgery Treatment of complications following surgery, including additional medical and/or surgical services performed during the postoperative period that do not require a return to the operating room Postoperative visits and postsurgical care related to the initial surgery including, but not limited to, the following: Dressing changes Wound care (incision care) Removal of sutures/staples Removal of lines (eg, intravenous) and tubes/drains Removal of cast

Policy

The Company has established the following requirements to report Modifier 24: The evaluation and management (E&M) service is performed by the same physician who performed the original surgical procedure. The E&M service is unrelated to the condition for which the original (major or minor surgery) surgical procedure was performed, regardless of place of service. Postoperative medical management provided by the physician is only eligible to be reported with Modifier 24 in the following circumstances: The care is for immunotherapy management furnished by the transplant surgeon, as documented in the individual's medical record. The care is for critical care services unrelated to the surgery for a seriously injured or burned individual who is considered critically ill or injured and requires constant physician attendance, as documented in the individual's medical record. The care provided during the inpatient visits following surgery is not related to the initial surgery, as documented in the individual's medical record. REQUIRED DOCUMENTATION The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agencies, therapies, other health care professionals, and test reports. The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Claims submitted with Modifier 24 are subject to post-payment clinical review and potential retractions for inappropriate use.

Guidelines

This policy is consistent with the reporting requirements established by Current Procedural Terminology (CPT) and the Centers for Medicare & Medicaid Services (CMS). The following are inappropriate uses of Modifier 24: The evaluation and management (E&M) service is related to the standard postoperative management of the original surgical procedure. The E&M service is related to complications following the original surgical procedure. The subsequent procedure or service performed is more accurately described by a different procedure code and/or modifier.

References

Beebe M, Dalton JA, Espoonceda M, et al, eds. CPT® 2008: Professional Edition: Current Procedural Terminology. 4th ed. Chicago, IL: AMA Press; 2007. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12 - Physicians/nonphysician practitioners. §30.6.6: Payment for evaluation and management services provided during global period of surgery. [CMS Web site]. 05/19/06. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed August 7, 2008. Hall DC, Orme N, eds. 2008 Ingenix University: Understanding Modifiers.Salt Lake City, UT: Ingenix/Medicode; 2007. Highmark Medicare Services. Medicare Part B Reference Manual. Appendix B: Modifiers. B-2: Global surgery. 24: Unrelated evaluation and management service by the same physician during a postoperative period. [Highmark Medicare Services Web site]. 01/01/08. Available at: http://www.highmarkmedicareservices.com/partb/refman/pdf/appendix-b.pdf. Accessed August 6, 2008. Highmark Medicare Services. Medicare Part B Reference Manual. Chapter 22: Global surgery & related issues. [Highmark Medicare Services Web site]. 01/01/07. Available at: http://www.highmarkmedicareservices.com/partb/refman/pdf/chapter22.pdf. Accessed August 6, 2008.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policy still apply. The following procedure codes are eligible to be reported with Modifier 24 (not all codes listed below are covered and eligible for reimbursement consideration): 0188T 0189T 92002 92004 92012 92014 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99281 99282 99283 99284 99285 99288 99291 99292 99304 99305 99306 99307 99308 99309 99310 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99339 99340 99341 99342 99343 99344 99345 99347 99348 99349 99350 99354 99355 99356 99357 99358 99359 99360 99363 99364 99366 99367 99368 99374 99375 99377 99378 99379 99380 99381 99382 99383 99384 99385 99386 99387 99391 99392 99393 99394 99395 99396 99397 99401 99402 99403 99404 99406 99407 99408 99409 99411 99412 99420 99429 99441 99442 99443 99444 99450 99455 99456 99460 99461 99462 99463 99464 99465 99466 99467 99468 99469 99471 99472 99475 99476 99477 99478 99479 99480 99499
ICD Procedure	N/A
ICD Diagnosis	N/A
HCPCS Level II	The following procedure codes are eligible to be reported with Modifier 24 (not all codes listed below are covered and eligible for reimbursement consideration): G0101 G0175 G0245 G0246 G0337 G0378 G0379 G0402 G0406 G0407 G0408 G0425 G0426 G0427 G9050 G9051 G9052 G9053 G9054 G9055 S0265 S0610 S0612 S0613 S5180
Modifier	Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period
Revenue Codes	N/A

Cross References

Version Effective Date: 01/01/2010