The Centers for Medicare & Medicaid Services recently published proposed rules for proper use of modifier 24 and 25 in evaluation and management (E&M) coding. Recognizing the global process period is critical for attributing modifiers 24 and 25. Global periods are typically zero, ten, or ninety days after the process, with additional preoperative days possible.
Modifier 24’s Appropriate Use
In the following cases, use modifier 24 in conjunction with the appropriate level of E&M service:
- The same physician performs an unassociated E&M service starting the day after the 10- or 90-day postoperative period.
- The information indicates that the service was solely for the treatment of the underlying medical condition and not for postoperative care.
- The same physician manages immunosuppressive therapy during the postoperative period of a transplant.
- The same physician works chemotherapy during the postoperative period of a procedure.
- The same physician performs unrelated intensive care during the postoperative period. The exact diagnosis as the original method could be used for the new E&M service if the problem arises at a different anatomical site.
Modifier 24 should not be used in the following situations:
- The E&M service is for surgical complications or diseases.
- The service is for surgical removal or other wound care.
- The surgeon admits a patient to a skilled nursing facility for a surgical-related condition.
- The paperwork in the medical records clearly shows that the E&M service is associated with the surgery.
- The service is provided outside of the procedure’s post-op period.
- Services are provided on the same day as the procedure.
- Regular postoperative exams are conducted.
Assigning both Modifiers 24 and 25
There are times when multiple surgery modifiers must be reported on a claim.
The following is an example of appropriate reporting of modifiers 24 (Unrelated E/M by the same physician during a postoperative period) and 25 (Separately identifiable E/M by the same physician on the same day of the procedure) on the same E/M code. A doctor performs serious surgery and then sees the patient for an unrelated E/M visit within the global period. During this unassociated E/M visit, the physician specifies the need for routine surgery or other procedure. This minor surgery/other procedure is substantial, distinct from the E/M, and unrelated to the original major surgery.
Modifiers 24 and 25 are both suitable to include in the E/M code. So E/M service is irrelevant and occurs during the postoperative period of the painful surgery; the 24 modifier is appropriate. The 25 modifiers are required to specify that the minor surgery/procedure performed on the same day is distinct from the E/M service.
Furthermore, a 79 modifier may be necessary for the little surgery procedure code to suggest that the process is unrelated to the painful surgery.
The use of modifiers 24 and 25 in E&M coding may appear perplexing, but the regulations above should assist. When you fully comprehend the global process period, it will be easier to determine when to use modifiers 24 and 25.
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