Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period

Policy #:03.00.15o

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

Coverage is subject to the terms, conditions, and limitations of the member's contract.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

In certain circumstances, it may be necessary for a physician or other qualified health care professional who performed a minor or major surgical procedure to provide an evaluation and management (E & M) service in the postoperative period that is unrelated to the surgical procedure. The E & M service should be appended with modifier 24 to indicate that it is not post-operative care related to the surgical procedure. Therefore, the E & M service may be eligible for separate reimbursement consideration by the Company.
APPROPRIATE USES OF MODIFIER 24

It is appropriate to append modifier 24 when any of the following circumstances apply:
  • An unrelated E & M service performed beginning the day after the procedure, by the same physician or other qualified health care professional, during the post-operative period.
  • The service is for the evaluation and management of the underlying condition that prompted the surgical procedure.
  • An E & M provided by the same physician or other qualified health care professional for post-operative medical management in any of the following circumstances:
    • The management of immunosuppressant therapy during the post-operative period of a transplant
    • The management of chemotherapy during the post-operative period of a surgical procedure

INAPPROPRIATE USES OF MODIFIER 24

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 (e.g., suture removal or wound treatment, which are part of the surgical package).
  • The E & M service is related to complications resulting from the original surgical procedure, which is part of the surgical package.
  • The service occurs outside of the post-operative period of the original surgical procedure
  • The service is rendered on the same day of the original surgical procedure.
  • The service being reported is not an E & M service.

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, and other health care professionals, as well as 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 review and potential retractions for inappropriate use.

BILLING REQUIREMENTS

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

This policy is consistent with Current Procedural Terminology (CPT) and Centers for Medicare & Medicaid Services (CMS) reporting requirements.

Description

A physician or other qualified health care professional may need to indicate that an evaluation and management (E & M) service was performed during a postoperative period for reason(s) unrelated to the original procedure. This circumstance may be reported by appending modifier 24 to the appropriate level of E & M service.


As defined by the Centers for Medicare & Medicaid Services (CMS) and applied by the Company, reimbursement for a surgical procedure includes a standard global surgical package, which includes preoperative, intraoperative, and postoperative services.


References



Centers for Medicare & Medicaid Services. Global Surgery Booklet. MLN Booklet. [CMS Web site]. September 2018. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf. Accessed October 9, 2019.

Novitas Solutions, Inc. Modifier 24 Fact Sheet. 02/15/17. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00101583. Accessed October 9, 2019.

Novitas Solutions, Inc. Global Surgery Modifiers. 11/01/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144547. Accessed October 9, 2019.

Optum360. Understanding Modifiers 2019. West Salt Lake City, UT: Optum360; 2018.


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)

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 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)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifier:

24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional during a Postoperative Period


Coding and Billing Requirements


Cross References


Policy History

REVISION FROM 03.00.15o
12/16/2019This version of the policy becomes effective 12/16/2019. It reaffirms the Company's continued position on reporting of modifier 24.

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: 12/16/2019
Version Issued Date: 12/16/2019
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.