When can one report an Evaluation and Management (E/M) code on the same day as a procedure defined by a Current Procedural Terminology (CPT) code that has a global period? And when is an E/M code reportable within the postoperative global period of a 10- or 90-day global procedure? These are 2 questions which are vexing to many, yet important to understand to allow appropriate reimbursement of services provided without running into trouble with regulators. While always important, these questions have recently come under greater scrutiny due to the concern and risk of overutilization along with an increase in audits and even prepayment audits from insurers. There are those who have been accused of fraudulent billing by either consciously evading the rules or not knowing the rules; as one may be aware, the litmus test of proper billing is that providers should have known the rules before seeking reimbursement for services.

The first step in this process is understanding what has already been paid when reporting a CPT code. Once that is known, one can then determine if an E/M code can additionally be reported. The valuation of a CPT code includes the associated same-day preprocedural work (seeing and examining the patient, preparing the patient for the procedure, getting consent, ordering medications, etc), the intraprocedural work (performing the procedure itself), and the associated postprocedural work. The postprocedural work that has been valued already is the associated postoperative work on the same day for 0-day global procedures, and for the next 10 or 90 days for a 10- or 90-day global procedure, respectively. Postoperative work includes writing orders, talking to the patient and family, coordination of the patient’s care, hospital and office visits, prescribing medications, changing lines and catheters and dressings, and typically the management of any complications of the procedure managed outside of a designated procedure/operating room.

Therefore, to additionally report an E/M service, one would have to perform medically necessary and indicated yet separate and identifiable work from that of the procedure that is being performed and its associated work, appended with the appropriate modifier. These rules apply not only to our surgical procedures (radical prostatectomy, cystoscopy, etc), but also to nearly any procedure with a designated CPT code that has a global period. In urology, this includes even seemingly minor procedures, including intramuscular injection (CPT 96372), intravenous infusion (CPT 96374), bladder instillation of anticarcinogenic agent (CPT 51720), insertion of temporary indwelling bladder catheter (CPT codes 51702 and 51703), and the like. Misunderstanding of the reporting criteria and/or misuse of coding can lead to denials and take-backs, and even up to being accused of fraudulent billing.

So let’s take a deeper look at Modifiers 24 and 25. Please note that coding is often based upon interpretation, and the examples listed below are opinion and what are felt to be best practices based upon the modifier descriptor definition, but do not constitute legal advice.

Modifier 24: Unrelated E/M Service by the Same Physician/Other Qualified Health Care Professional During a Postoperative Period

Modifier 24 appended to an E/M service communicates to an insurer that the provider is seeing and managing a patient for an unrelated reason within a 10- or 90-day postoperative global period. An E/M service appended with Modifier 24 should only be reported when appropriate criteria are met. As noted above, the global period of a procedure includes the work performed as related to the procedure and the recovery from the procedure, including inpatient and outpatient visits and visits with different diagnoses that are actually complications of the procedure performed. What is not included in the CPT code and global is the evaluation and management of unrelated diagnoses, management of the underlying condition, or an added course of treatment which is not part of normal recovery from surgery.

Appropriate use: It would be appropriate to report an E/M service within a global period if the patient is being seen for an unrelated reason during a 10- or 90-day global postoperative period. For example, if 30 days after a laparoscopic radical prostatectomy (CPT code 55866, 90-day global procedure) a patient presents with a new obstructing ureter stone, the evaluation and management of that condition should be noted and the E/M service reported with Modifier 24. It is important to remember that all providers in the same practice and specialty are considered the same provider; the same rules apply if a patient is on the schedule to see one of the partners of the provider who performed the procedure. It would be appropriate if a patient needs further care on their underlying condition (think: managing chemotherapy or radiation therapy for cancer) within a global period.

Inappropriate use: It would be inappropriate to report an E/M code with Modifier 24 for routine postoperative care or for managing a surgical complication such as infection, removal of sutures, or other wound treatment, as these treatments are already part of the surgery package and have been “prepaid.” For example, if a patient needs to be seen for a wound infection and gets antibiotics or even some in-office local therapy, that is all included even if a different diagnosis code is used. Another example: the patient has urinary retention after a 90-day global procedure such as a hydrocelectomy (90-day global) if the patient had not previously had known urinary retention issues and the problem is a side effect of the surgery or anesthesia.

Modifier 25: Significant, Separately Identifiable E/M Service by the Same Physician/Qualified Health Care Professional on the Same Day of the Procedure or Other Service

Modifier 25 appended to an E/M service communicates to an insurer that the provider is seeing and managing a patient for a separately identifiable reason on the same day as a procedure. An E/M service appended with Modifier 25 also should only be reported when appropriate criteria are met. Procedures performed are already valued to include the preoperative work and all of the associated postoperative work of that designated procedure. When determining if it is appropriate to report an E/M service using Modifier 25, one has to ask if there are unrelated conditions that are also being addressed (and medically necessary to do on the same date) or if there signs, symptoms, and/or conditions the physician/other qualified health care professional must address before deciding to perform a procedure or service. One does not need to have different diagnosis codes to report an E/M service with Modifier 25 as long as the appropriate criteria are met.

Appropriate use: A classic example of appropriate reporting of an E/M code on the same day as a procedure is a patient undergoing a microscopic hematuria evaluation by cystoscopy (CPT code 52000, 0-day global) where a bladder tumor is found. If the provider then discussed this finding along with the next steps (such as scheduling the patient for a bladder tumor resection), a separate and identifiable E/M service is performed. In this example, different diagnosis codes are used. Another example of the appropriate use of Modifier 25 is when one sees and examines a new patient in the emergency room who is presenting with a ureter stone and scheduling the patient for a cystoscopy with stent placement (CPT code 52332, 0-day global procedure) on the same day. Please note that even though the same diagnosis code (N20.1 ureter stone) is used for both the E/M service and procedure, it is the extra work above and beyond that allows billing of the E/M code as this was the evaluation that led to the decision to perform surgery. This is in contrast to a patient who had been seen in the office with a ureter stone on a prior day and presented for an elective cystoscopy with stent placement, when no E/M service would be billed.

Inappropriate use: One should not report an E/M service using Modifier 25 on the same day as a procedure if there are no new medically necessary E/M services provided. For example, a patient presents for a 6-week course of intravesical therapy for bladder cancer. For each of the 6 visits, the procedure code (CPT code 51720) is a 0-day global, and since the plan is already in place, no separate and identifiable E/M service is performed. Talking to the patient preprocedure, viewing the patient’s urine, and ensuring that the patient is safe to undergo the procedure are all valued into the CPT code. Similarly, patients who are on a course for surveillance cystoscopies should not have an E/M service reported on the dates of the cystoscopy without a different reason. It would be inappropriate to report an E/M service using separate and unrelated diagnoses on the same day as a procedure if it was not medically necessary to do so (for example, if it was just recently discussed or irrelevant, etc). As medical necessity is the overarching criterion to report services, it would be inappropriate to additionally manage a condition that was not medically necessary on the same date as a procedure merely to additionally report an E/M service.

Conclusions

Modifier 24 and Modifier 25 are important E/M modifiers but must be used with caution as there is a high risk of audit when these codes are used. A thorough understanding of the appropriate and inappropriate uses of these codes is vital to appropriate reporting and reimbursement for work performed.