Notification



Notification Issue Date:



Claim Payment Policy


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

Policy #:03.00.15n

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

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.



Policy

In certain circumstances, it may be necessary for a physician who performed a minor or major surgical procedure to perform an evaluation and management (E&M) service in the postoperative period of the surgical procedure for a reason(s) unrelated to the original surgical procedure. In this situation, the E&M should be appended with modifier 24 to indicate that the E&M service is not part of the global surgical package, and therefore, eligible for separate reimbursement consideration by the Company.

It is appropriate to append modifier 24 to the E&M services listed in the coding table of the policy, when all of the following apply:
  • The E&M service occurs in the postoperative period of the original surgical procedure.
  • The 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 managment provided by the physician in the following circumstances:
    • Care for immunotherapy management rendered by the transplant surgeon, when reported with an E&M.
    • Care for critical care services for a seriously injured or burned individual, when reported with an E&M.

The following are inappropriate circumstances for appending modifier 24:
  • The 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.

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.

BILLING REQUIREMENTS

The CPT/HCPCS codes listed in the coding table are reportable with modifier 24.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, evaluation and management (E&M) services appended with Modifier 24 are covered under the medical benefits of the Company's products.

MEDICARE

This policy is consistent with Medicare's reporting requirements. The Company's payment methodology may differ from Medicare.

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

References


2010 Ingenix Learning: Understanding Modifiers. West Valley City, UT: International Standard Book Number (ISBN) 978-1-60151-280-2.

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]. 06/01/06. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed January 10, 2011.

Highmark Medicare Services. Medicare A/B Reference Manual. Chapter 20: Coding Resources/Modifiers. [Highmark Medicare Website]. 10/19/2010. Available at: https://www.highmarkmedicareservices.com/refman/chapter-20.html#5. Accessed January 10, 2011.

Highmark Medicare Services. Medicare A/B Reference Manual. Chapter 22: Global Surgery & Related Services. [Highmark Medicare Website]. 10/19/2010. Available at: https://www.highmarkmedicareservices.com/refman/chapter-22.html. Accessed January 10, 2011.




Coding

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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

The following CPT codes are eligible to be reported with Modifier 24 (not all codes listed below are covered and eligible for reimbursement consideration):

0188T 0189T 0359T 0360T 0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T 0369T 0370T 0371T 0372T 0373T 0374T 34839 92002 92004 92012 92014 93792 93793 96160 99024 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99224 99225 99226 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 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 99429 99441 99442 99443 99444 99446,99447,99448,99449,99450 99455 99456 99460 99461 99462 99463 99464 99465 99466 99467 99468 99469 99471 99472 99475 99476 99477 99478 99479 99480 99483 99484 99485 99486 99487 99489 99490 99492 99493 99494 99495 99496 99497 99498 99499


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



The following HCPCS codes are eligible to be reported with Modifier 24 (not all codes listed below are covered and eligible for reimbursement consideration):

D9311 G0101 G0102 G0128 G0175 G0181 G0182 G0245 G0246 G0247 G0337 G0378 G0379 G0380 G0381 G0382 G0383 G0384 G0402 G0406 G0407 G0408 G0425 G0426 G0427 G0436 G0437 G0438 G0439 G0463 G0473 G0501 G0505 G0506 G0508 G0509 G0513 G0514 G9050 G9051 G9052 G9053 G9054 G9055 S0260 S0265 S0601 S0610 S0612 S0613 S9117 S9123 S9124 S9140 S9141 S9455



Revenue Code Number(s)

N/A


Misc Code

Modifier:

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



Coding and Billing Requirements


Cross References


Policy History

REVISION FROM 03.00.15n
01/01/2018Policy # 03.00.15m has been identified for the Annual CPT/HCPCS code updates, effective 01/01/2018. The policy will be reissued as 03.00.15n.

CPT
The following CPT codes have been removed from the policy: 99363 and 99364

The following CPT/HCPCS codes have been added to this policy: 93792, 93793, 99483, 99484, 99492, 99493, 99494, G0513 and G0514


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 01/01/2018
Version Issued Date: 01/10/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.