Policy Statement
All surgical procedures and some procedural services include a certain degree of physician involvement or supervision which is integral to that service. For those procedures and services, a separate E&M service is not normally reimbursed. However, a separate E&M service may be considered for reimbursement, if the patient’s condition requires services that are unrelated to the surgical procedure, in the postoperative period. To identify these circumstances, modifier 24 is attached to the E&M code.
Modifier 24 can be appended to an E&M code used in conjunction with a minor or major surgical procedure.
Modifier 24 should only be appended to an E&M code rendered during the postoperative period (10 or 90 days) when the service is unrelated to the surgical procedure.
This includes but is not limited to:
- The E&M service must be performed by the same physician or a member of the same group practice with the same specialty.
- The diagnosis for the E&M service must be distinct from the postoperative diagnosis.
- Documentation in the patient’s medical records must clearly support the unrelated nature of the visit and the medical necessity for the additional E&M service.
- Modifier 24 is not appropriate for use with the procedures or services performed by a different physician or for complications related to the surgical procedure.
Our health plan does not separately reimburse an E&M code billed with modifier 24:
- If the E&M code has a primary diagnosis that is associated with the surgical procedure.
- If the E&M code has a diagnosis that is a complication of the surgical procedure or an aftercare diagnosis.
The submission of modifier 24 appended to an E&M code indicates that documentation is available in the patient’s medical records that will support the unrelated nature of the E&M service. The patient’s medical records may be reviewed for coding validation.
References
Cross References
