Coding Corner: Using a Modifier -24 During the Global Period | Carolyn Haunschild, MD
Most services provided after surgery are covered under a global period. Reimbursement for these normal post-operative services has already been bundled into the payment for the procedure. Minor procedures are covered under a 10-day global period and major surgeries are covered under a 90-day global period. The global period includes all services related to the surgical procedure including routine post-operative visits and care and supplies for post-operative complications. Added treatment courses that are not a normal part of surgical recovery can be billed for using a modifier -24. Gynecologic oncologists often encounter situations in the post-operative period where new treatment recommendations are made based on the surgical pathology. These additional services can be billed for using a modifier -24 provided the diagnosis and ICD-10 code for the new encounter are distinct from the diagnosis related to the surgery. Below are some examples of use of modifier -24 in the post-operative period. Documentation must support the unrelated service which should be separate and distinct from routine post-operative care.
Scenario 1: A patient undergoes a primary debulking surgery for an adnexal mass and peritoneal carcinomatosis. Final pathology reveals ovarian cancer. You plan to provide her with adjuvant chemotherapy in the post-operative setting.
In this case, the patient has a new diagnosis C56.1- C56.9 and you provide service Z71.89 Other unspecified counseling. It would be appropriate to bill for service 99215 using modifier -24. For subsequent pre-chemotherapy visits, ICD-10 code Z01.818 Encounter for examinations prior to antineoplastic chemotherapy or other codes related to management of chemotherapy side effects may be appropriate.
Scenario 2: A patient with endometrial cancer who underwent a staging surgery is seen for a post-operative visit. She has high intermediate risk factors and is counseled on adjuvant treatment options. After discussion she is referred for radiotherapy.
When you are counseling a patient on chemotherapy or radiotherapy but not directly providing the service, you can code the encounter as ICD-10 Z71.89 Other unspecified counseling and bill for the appropriate E/M for the encounter with modifier -24. If billing for time, the total time should be related to time spent on counseling as time for routine post-operative care has already been reimbursed as part of the global surgery fee.
Scenario 3: You performed a bilateral salpingo-oophorectomy on a premenopausal patient at high risk for cancer. In the post-operative setting you provide counseling on and prescribe hormone replacement therapy (HRT) for menopausal symptoms.
Whether or not a modifier -24 can be applied in this case depends on whether the outcome is expected or related to the surgery. In this case, surgical menopause is expected and discussion to start HRT may be made regardless of the patient’s symptoms or may even have been predetermined prior to surgery. However, in other scenarios, counseling and
treatment of menopausal symptoms may be unrelated to surgery (e.g., patient is already postmenopausal, symptoms pre-existing prior to surgery), and such patients may require an added course of treatment that can be billed with the appropriate evaluation and management (E/M) code and modifier -24.
Scenario 4: You perform a cervical conization for a patient with cervical dysplasia. Final pathology shows cervical cancer and you counsel her for a radical hysterectomy which is performed less than 6 weeks after conization.
While a cervical conization may seem like a “minor” procedure, CPT code 57520 is covered under the 90-day global period. In this scenario, the patient has a new diagnosis C53.1-C53.9 and is provided counseling for treatment of this newly identified disease. An E/M code of 99214 or 99215 with a modifier -24 may be appropriate. Additionally, the subsequent surgery would be reimbursed under CPT code 58210. A modifier -79 would need to be added to this procedure and a new 90-day global period would start.
Scenario 5: You perform a dilation and curettage for a young patient with endometrial cancer. She presents for a two-week post-operative visit and you counsel her on fertility sparing treatment.
In this case, CPT code 58120 is covered under a 10-day global period. At a two-week post-operative visit, a modifier -24 is no longer needed. The visit can be billed using the appropriate 99211-99215 code.
Carolyn Haunschild, MD, is a Gynecologic Oncologist at the University of California, Los Angeles.