Correct use and abuse of modifier 24

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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My patient returned for suture removal seven days after the excision of a squamous cell carcinoma on the arm. The wound looked great, but during the visit he pulled out a long list of additional medical problems he wanted addressed. Can I bill for the visit even though it occurred during the 10-day global period?

Yes. You can bill for the services but if you fail to append modifier 24 to the claim, payment may be denied. Modifier 24 is intended to prevent inappropriate bundling of separately identifiable medically necessary Evaluation and Management (E/M) services provided during the global period following a procedure. It is important to understand that procedures with a global period typically have a follow-up visit already calculated into the value of the code. For example, code 11643 (excision, malignant lesion, face, 2.1 to 3.0 cm) already includes a 99213 visit in the 10-day global period to evaluate the wound, remove sutures and discuss the lab report with the patient. These services would not be separately reportable, as they were already paid for as part of the payment you received for the 11643 code.

However, patients often present with unrelated complaints during a global period. When separately identifiable medically necessary E/M services are provided during a post-procedure global period, modifier 24 is used to prevent inappropriate bundling of those services and denial of payment.[pagebreak]

Mr. Smith returns to the clinic for excision of a biopsy-proven basal cell carcinoma. One week later, he returns again for suture removal, wound evaluation and discussion of his prognosis. It would be inappropriate to report a separate evaluation and management (E/M) code on either of these dates of service unless clearly identifiable separate cognitive services were provided.

But what if Mr. Smith presents with poison ivy on the date he was scheduled for suture removal? In this case, modifier 24 would be appropriate to override the CCI edit that would have denied payment for the legitimate separately identifiable and medically necessary cognitive service.

While it is not necessary to have a different diagnosis from the diagnosis that supported the procedure, it is necessary that there be medical necessity to perform the separate service and that the E/M service provided goes beyond the normal follow-up visit already included in the value of the procedure code.

When using modifier 24, both services must be significant, separate, and distinct. The documentation must clearly demonstrate that:

  • The purpose of the visit was other than evaluating the wound, removing sutures, or discussing prognosis.
  • The purpose of the separate E/M service was to evaluate a specific complaint.
  • The complaint or problem justifies a separate billable service, and the services were performed.
  • You performed extra work above and beyond the typical follow-up visit associated with the procedure code.
  • Documentation for the E/M service must include the key elements (history, examination, and/or medical decision making) required for the selected code.

Be prepared to appeal to your local Medicare carrier if your use of modifier 24 is denied; it is a common denial, but you can win your appeal if you’ve used the modifier correctly.