CODING Q&A

A Tougher Medicare Audit Environment for Modifier 24

Information Provided by Riva Lee Asbell

The OIG has placed modifier 24 under investigation in 2010 with increased focus on CERT (Comprehensive Error Rate Testing) and MAC (Medicare Administrative Contractor) pre-audits that request ad ditional documentation within a given time frame (usually 30 days). If the additional information is not submitted as directed, the claims will be de nied and you may be referred for fraud evaluation. Make sure your office staff lets you know of these important requests and handles them properly.

The OIG 2010 work plan states:

“Evaluation and Management Services During Global Surgery Periods

“We will review industry practices related to the number of evaluation and management (E&M) services provided by physicians and reimbursed as part of the global surgery fee. … Under the global surgery fee concept, physicians bill a single fee for all of their services usually associated with a surgical procedure and related E&M services provided during the global surgery period…”

CPT Definition: “[Modifier] 24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period:

The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure…”

For Medicare, the postoperative or global period defines whether a surgical procedure is major or minor: 90 days for a major procedure and 0 or 10 days for a minor one. During this time period, related office visits cannot be billed.

Many physicians question why there is no compensation for dealing with related problems treated in the office during the postoperative period. The global fee for ophthalmic surgical procedures is divided into three portions: (1) 10% of the fee is allotted for preoperative care; (2) 70% of the fee is allotted for intraoperative care; (3) 20 to 30% of the fee is designated for postoperative care.

As I explain in my book, Tips on Ophthalmic Surgical Coding by Subspecialty, “If a complication occurs, such as hyphema after cataract surgery, you cannot charge additionally for the medical management of that problem unless the management requires a return to the OR.”

I want to emphasize that it is the office visit and medical treatment that is not billable, not treatment requiring surgical services.

Clinical Examples/Not billable

► Panretinal photocoagulation was performed in the right eye for proliferative diabetic retinopathy. The patient presents with new floaters and vitreous hemorrhage in the right eye. If the encounter is related to the disease process, you should not bill for the office visit.

► Focal laser was performed on the right eye and the patient returns with a corneal abrasion. Since the corneal abrasion was related to the procedure and does not require surgical treatment, the office visit is not billable.

► A retinal detachment repair was performed in the right eye using a scleral buckle. In the global period, the retina redetaches and after examination further surgery is scheduled. The office visit is not billable since the condition is related to the surgery.

Clinical Examples/Billable

► PRP had been performed on the left eye and patient presents with a vitreous hemorrhage in the right eye. Patient has bilateral PDR; however, the right eye had never been treated, nor was a vitreous hemorrhage previously diagnosed. An office encounter can be billed under Modifier 24 for new problems in the contralateral eye that present for the first time.

In a group practice, the patient is followed by the Glaucoma Service and is in the global period for placement of an aqueous shunt in the right eye. Patient presents with a sudden-onset vitreous hemorrhage and is referred to the Retina Service. The encounter may be billed with modifier 24. RP

CPT codes ©2010 American Medical Association.