Modifier -24
Unrelated evaluation and management service (or eye visit code) by the same physician during postoperative period.
-or-
Office visit in the postoperative period not related to the original surgery (eg, new symptoms, significant changes in eye health requiring an evaluation of an unrelated problem or fellow eye).
When a patient presents for a new condition during the global period of a procedure, the first question should be: is it related or unrelated? If unrelated, billing can be tricky because the when and how of that billing isn’t always straightforward. Exploring the definition of modifier -24 and applying it to retina case studies will help you to master this essential modifier.
APPROPRIATE USE
The modifier’s definition (see Modifier -24) provides guidance on appropriate use when reporting an evaluation and management (E/M) or eye visit code that is considered unrelated during the postoperative period. When this modifier was originally released, it was anticipated in a low percentage of claims. As a result, insurance payers are concerned about its proper use. In fact, some insurance payers may automatically deny claims with modifier -24 and only pay upon appeal. Appropriate use and comprehensive chart documentation will ensure approved claims.
DIFFERENT DIAGNOSIS DOESN’T ALWAYS MEAN UNRELATED
When the patient is evaluated during the global period with a new diagnosis, that does not necessarily mean the examination is billable with modifier -24. If the problem is completely unrelated to the original surgery, it would be appropriate to bill. However, if the new condition is related, or is a complication of the surgery, even when a completely different ICD-10-CM is used, the examination is considered a postoperative visit.
Ask yourself, would the patient have this condition if they didn’t have surgery? If the answer is no, this would be considered related, or a complication, and coding the examination with modifier -24 would not be appropriate.
CASE EXAMPLE: NEW SYMPTOMS, FELLOW EYE
During the global period of a panretinal photocoagulation (CPT code 67228) in the right eye for proliferative retinopathy, a patient presents with complaints of significant visual disturbance in the left eye. The diagnosis for the encounter is diabetic macular edema, left eye.
Report the appropriate level of E/M or eye visit code appended with modifier -24 linked to the diabetic macular edema ICD-10-CM code as the new problem, the fellow eye is unrelated.
CHIEF COMPLIANT IS CRUCIAL
When the patient presents with an unrelated symptom, the chief complaint should support the medical necessity for the unrelated examination. If the chief complaint documents “patient here for 1 week s/p vitrectomy surgery” and does not expand on the new, unrelated symptoms, the documentation may not support medical necessity.
CODE THIS CASE
A patient is seen in the global period following cataract extraction with IOL implantation and is referred to a retina specialist for cystoid macular edema. The diagnosis of cystoid macular edema is related to the cataract surgery.
Is it acceptable to bill the examination or is this a postoperative visit? Is a modifier -24 necessary?
The answer depends on if the cataract surgeon was an internal or external referring physician.
- If the cataract surgeon is in an outside practice, the examination is billable, and a modifier is not necessary, as the retina specialist does not share the global period.
- If the cataract surgeon and retina specialist are in the same group practice, the examination is not billable, as it is considered a postoperative visit.
GROUP PRACTICES SHARE THE SAME GLOBAL PERIOD
Physicians of the same group ophthalmic practice share the global surgical package. If, during the postoperative period, the surgeon’s associate in the same practice sees the patient for related follow-up or complications, the office visit would still be considered global.
When you are on call for another group, it is as if you are the operating surgeon. Visits related to surgery are postoperative and are not separately billable.
More information on modifiers and retina coding fundamentals can be found in the Retina Coding: Complete Reference Guide available at aao.org/store.
