What Is Modifier 24 in Medical Billing?
Navigate medical billing complexities with Modifier 24. Learn its proper application for distinct services during a global surgical period to prevent denials.
Medical billing relies on a system of codes and modifiers. Current Procedural Terminology (CPT) modifiers are alphanumeric codes that provide additional information about a service or procedure. They clarify circumstances that alter payment for a service, ensuring proper reimbursement and compliance. Modifier 24 distinguishes services provided during a patient’s postoperative period.
Defining the Postoperative Period
Understanding the postoperative period is important for Modifier 24. Many surgical procedures are bundled into a “global surgical package.” This package includes all necessary services by a surgeon before, during, and after a procedure. This bundling ensures consistent payment, preventing separate billing for routine care.
Global surgical packages have defined postoperative periods, categorized as 0-day, 10-day, or 90-day. A 0-day global period applies to minor procedures like endoscopies, including only the day of the procedure. A 10-day period covers the procedure day and 10 subsequent days. A 90-day period applies to major surgeries, covering one day before, the procedure day, and 90 days after. Services not separately billable include preoperative visits after the decision for surgery, immediate postoperative care, follow-up visits related to recovery, and management of complications not requiring a return to the operating room.
Appropriate Use of Modifier 24
Modifier 24 is defined as an “Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period.” It is appended to Evaluation and Management (E/M) codes (99202-99499) and some general ophthalmological services (92002-92014) to indicate an E/M service during a global surgical period was for a condition unrelated to the original surgery. Its correct application ensures proper reimbursement for distinct services and avoids claim denials.
Modifier 24 requires the E/M service to be “unrelated” to the initial surgery. This means the patient is seen for a new problem, not a complication, routine postoperative care, or follow-up related to surgical recovery. For example, if a patient has hip replacement surgery and later, within the 90-day global period, visits the same surgeon for a new skin rash, Modifier 24 applies to the E/M service for the rash. Similarly, if a patient experiences an unrelated exacerbation of a chronic condition, such as hypertension, Modifier 24 applies to the E/M service for managing it.
Modifier 24 should not be used for services part of the global package. These include routine postoperative visits, wound checks, suture removal, or treatment for surgical complications (e.g., incision site infection), unless a return to the operating room is required. If the E/M service relates to the initial surgery, even for pain management from the procedure, it is included in the global fee. It is not applicable for services on the same day as the original procedure.
Supporting Documentation for Modifier 24
Medical record documentation is important when using Modifier 24. Insufficient documentation often leads to claim denials or audits. The medical record must support that the Evaluation and Management (E/M) service was unrelated to the prior surgery.
The patient’s chart should include a distinct diagnosis code for the unrelated condition, separate from the surgical diagnosis. Documentation should provide a narrative explaining why the visit falls outside normal postoperative care for the original surgery. This includes detailing the history, examination findings, and medical decision-making for the new, unrelated issue. Avoid using the original surgery’s diagnosis or related diagnoses for the unrelated E/M service. Payers may request additional documentation if the diagnosis code alone does not demonstrate the unrelated nature of the visit.