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MA PPO Host - Claim Payment Policy Bulletin

Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
MA03.009e

Policy

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 policy applies to professional and outpatient facility claims.

In certain circumstances, it may be necessary for a professional provider 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 postoperative care related to the surgical procedure, and therefore the E&M service ​is eligible for reimbursement consideration by the Company.

It is appropriate to append modifier 24 to an E&M service in any of the following circumstances:
  • An E&M​ service, unrelated to the surgical procedure, performed by the same professional provider or other qualified health care professional, during the postoperative period.
  • The service is for the evaluation and management of the underlying condition that prompted the surgical procedure.
    • ​Documentation must substantiate that the service is being performed to address the underlying condition and not related to postoperative care.​​
  • An E&M service provided by the same professional provider or other qualified health care professional for​ medical management in any of the following circumstances:
    • ​The management of immunosuppressant therapy during the postoperative period of a transplantation
    • The management of chemotherapy during the postoperative period of a surgical procedure 

​​It is inappropriate to append modifier 24​ to an E&M service in any of the following circumstances:

  • 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 postoperative 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 ​professional provider'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 pre- and post​payment review and potential denials or ​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

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

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. ​An E&M service appended with modifier 24 indicates a service that is not part of the standard global surgical package.

References

Centers for Medicare & Medicaid Services. Global Surgery Booklet. MLN Booklet. [CMS Web site]. September 2018. Available at: https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf​. Accessed February 19, 2025.

Novitas Solutions, Inc. Modifier 24 Fact Sheet. 02/15/17. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00101583. Accessed February 19, 2025.

Novitas Solutions, Inc. Global Surgery Modifiers. 11/01/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144547. Accessed February 19, 2025​​.

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

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A

Modifiers

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

Policy History

Revisions From MA03.009e:
03/05/2025
The policy has been reviewed and reissued to communicate the Company’s continuing position on Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period.
01/01/2024

​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
03/08/2023
This policy has been reissued in accordance with the Company's annual review process.​
07/12/2021This version of the policy becomes effective 07/12/2021​. It reaffirms the Company's continued position on reporting of modifier 24.​

Revisions From MA03.009d:
12/16/2019This version of the policy becomes effective 12/16/2019. It reaffirms the Company's continued position on reporting of modifier 24.

Revisions From MA03.009c:
01/01/2018Policy # MA03.009 has been identified for the Annual CPT/HCPCS code updates, effective 01/01/2018. The policy will be reissued as MA03.009c.

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

Revisions From MA03.009b:
01/01/2017This is a coding update policy.

Revisions From MA03.009a:
01/21/2015This is a coding update policy.

Revisions From MA03.009:
01/01/2015This is a new policy.
07/12/2021
07/12/2021
03/05/2025
MA03.009
Claim Payment Policy Bulletin
Medicare Advantage
No
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