CurrentAnthemPolicy G-06011

Modifier 24

Defines Anthem Blue Cross and Blue Shield Medicaid (Ohio Medicaid Managed Care) reimbursement criteria for billing Evaluation and Management (E/M) services with modifier 24 during a postoperative period and who may be reimbursed.

Policy Summary

PayerAnthem

PolicyModifier 24

Policy CodePolicy G-06011

Change TypeOperational wording change

Effective DateJun 11, 2025

Next Review Date

Key ActionAppend modifier 24 to the appropriate level of E/M service and ensure documentation shows the diagnosis and reason are unrelated to the original procedure.

SourceLink

POLICY UPDATE CHANGES

Removed the word 'limited' from the policy statement.

100%reimbursement when criteria met

3required criteria

3policy history entries

Reimbursement Criteria for Modifier 24

Modifier 24 Reimbursement Criteria

Anthem allows reimbursement for claims billed with modifier 24 when all the following conditions are met:

ALL of the following

The appropriate level of E/M service is billed and appended with modifier 24.
A diagnosis code unrelated to the original procedure is indicated for the E/M service.
The reason for the E/M service is clearly documented in the member's medical record.

Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate for the E/M service when the above criteria are met.

Reimbursement basis stated in policy.

Policy Summary

PayerAnthem

PolicyModifier 24

Policy CodePolicy G-06011

Change TypeOperational wording change

Effective DateJun 11, 2025

Next Review Date

Key ActionAppend modifier 24 to the appropriate level of E/M service and ensure documentation shows the diagnosis and reason are unrelated to the original procedure.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Codes, Reimbursement Level, and Billing Expectations

ModifierModifier

Modifier 24

Unrelated E/M service by same physician/qualified health care professional during postoperative period

CPT/HCPCS billing expectationmixed

No codes listed

Reimbursement level when criteria met

Reimbursement level100% of the applicable fee schedule or contracted/negotiated rate for the E/M service when modifier 24 criteria are met

Applicable serviceEvaluation and Management (E/M) service performed during the postoperative period of the original procedure

Condition for paymentPayment applies only when the appropriate level of E/M service is billed and appended with modifier 24

Documentation requirementReason for the E/M service must be clearly documented in the member's medical record

Diagnosis requirementA diagnosis code unrelated to the original procedure must be indicated for the E/M service

Billing, Documentation, and Denial Risk

Documentation Required

Billing and Documentation Requirements for Modifier 24

Append modifier 24 to the appropriate level of E/M service and ensure the member's medical record clearly documents that the diagnosis and reason for the E/M service are unrelated to the original procedure; follow authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

Bill the appropriate level of E/M service and append modifier 24.
Document a diagnosis code unrelated to the original procedure for the E/M service.
Ensure the reason for the E/M service is clearly documented in the member's medical record.
Follow authorization and medical necessity guidelines per member state of residence.

Denial Risk

Denial and Recoupment Risk if Modifier 24 Is Misused

Failure to use modifier 24 correctly may result in denial of the E/M service and/or recoupment or recovery of claim payment.

Incorrect or missing modifier 24 can lead to claim denial.
Noncompliance with coding/billing guidelines may prompt recovery or recoupment of payments.

Key Terms

Modifier 24 definition

DefinitionModifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period; used to indicate the same physician/qualified healthcare professional needed to perform an E/M service during the postoperative period for a reason unrelated to the original procedure

How reportedReported by adding modifier 24 to the appropriate level of E/M service

Typical global-period ruleE/M services performed during the postoperative period usually are considered part of the global surgical package unless unrelated and reported with modifier 24