Coding & Reimbursement

Understanding Modifier 24

By Suzanne L. Corcoran, COE

Confusion continues about when it is appropriate to use modifier 24 and other modifiers following surgery. This month I will attempt to clear up some of the mystery.

Q. Are all exams during the postoperative period included in the global surgical fee?

A. No. Nearly all patients are directed to return to the surgeon during the postoperative period for an eye exam related to the original surgical procedure. Sometimes the patient's complaint is unrelated to the original procedure. An unrelated evaluation and management (E/M) service (992xx) may be reported using modifier 24. Likewise, modifier 24 may be applied to an office visit reported with an eye exam code (920xx).

Q. What does modifier 24 mean?

A. CPT defines modifier 24 as "unrelated evaluation and management services by the same physician during a postoperative period." It goes on to say, "the physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure."

Q. What does "unrelated" mean in this context?

A. The problem or condition reported by the patient or identified by the surgeon is unconnected with the surgery in any way. It is not a complication of the procedure or associated follow-up care. Commonly, "unrelated" refers to the unoperated eye. It might also refer to another anatomical part of the operated eye that is superfluous or irrelevant to the surgery.

Q. May modifier 24 be used to report the decision to perform cataract surgery in the opposite eye?

A. Yes. When the decision for each surgery is made at separate times rather than simultaneously, and the second decision occurs within the postoperative period of the first cataract surgery, then modifier 24 applies. The standard of ophthalmic practice dictates that bilateral cataract surgery is rarely appropriate (e.g., bilateral phacomorphic glaucoma).

In residency, ophthalmologists learn to evaluate both eyes, but cataract surgery is almost always one-at-a-time. The outcome of the first surgery cannot be known in advance and has an important bearing on the plan for surgery in the contralateral eye. The medical necessity for each surgical procedure entails sequential evaluations and discrete documentation in the medical record.

Q. Will utilization of modifier 24 trigger a postpayment audit?

A. Possibly. The Office of the Inspector General and Medicare contractors closely monitor claims for reimbursement during the global surgery period. Frequent use of modifier 24 could trigger an audit.

Q. Should modifier 24 be used to report a diagnostic test in the global surgery period?

A. Not for Medicare and not for other payers unless you are specifically instructed to do so. Diagnostic tests, including diagnostic radiological procedures, are not included in the global surgery package. For example, modifier 24 would not be used with A-scan biometry in the global period.

Q. What other modifiers pertain to surgery in the global period?

A. There are several modifiers that are used during the global surgery postoperative period:

• Modifier 25 to identify a significant, separately identifiable E/M service on the same day as a minor surgical procedure.
• Modifier 57 to report an E/M service which resulted in the decision for major surgery.
• Modifier 58 to report a related procedure during the global period that was staged, more extensive or post-diagnostic.
• Modifier 78 to report a related surgery during the global period which resulted in a return to the operating room.
• Modifier 79 to report an unrelated surgery during the global period of another procedure. OM