MA PPO

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


Policy

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

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

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

Coding and Billing Requirements



Policy History

12/16/2019
12/16/2019
MA03.009
Claim Payment Policy Bulletin
Medicare Advantage
Yes