CurrentBlue Cross Blue Shield - MainePolicy G-06011

Modifier 24 reimbursement

This policy governs reimbursement for Evaluation and Management (E&M) services billed with Modifier 24 when performed by the same physician or qualified healthcare professional during the postoperative period and applies to providers submitting claims to AMH Health/Blue Cross Blue Shield - Maine.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 24 reimbursement

Policy CodePolicy G-06011

Change TypeClarified / Revised

Effective DateDec 27, 2022

Next Review Date

Key ActionAppend Modifier 24 to the E&M service and document an unrelated diagnosis code to support separate reimbursement.

SourceLink

POLICY UPDATE CHANGES

Title updated to remove 'Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Healthcare Professional during the Postoperative Period'; minor language and format changes; updated related policies section.

Definition updated on 09/14/2020 as noted in policy history.

100%reimbursement rate when criteria met

3required criteria count

1primary reference sources

Reimbursement Criteria for Modifier 24

Reimbursement criteria for Modifier 24

AMH Health allows reimbursement for E&M services during the postoperative period when all of the following criteria are met:

ALL of the following

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

Codes and Reimbursement Rate

ModifierModifierCovered

Modifier 24

Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Healthcare Professional During a Postoperative Period

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 24 reimbursement

Policy CodePolicy G-06011

Change TypeClarified / Revised

Effective DateDec 27, 2022

Next Review Date

Key ActionAppend Modifier 24 to the E&M service and document an unrelated diagnosis code to support separate reimbursement.

SourceLink

On This Page

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Reimbursement rate

Reimbursement rate100% of the applicable fee schedule or contracted/negotiated rate when criteria are met

Applies toEvaluation and Management (E&M) services performed during the postoperative period of the original procedure

Condition for paymentPayment applies only when all policy criteria are satisfied (E&M billed with Modifier 24; documented unrelated reason; unrelated diagnosis code)

Denial/recoupment riskFailure to use Modifier 24 correctly may result in denial and/or claim payment recoupment or recovery

Billing and Documentation Requirements

Denial Risk

Billing/documentation requirements and denial risk

When billing an Evaluation & Management (E&M) service furnished during the postoperative period for a reason unrelated to the original procedure, append Modifier 24 to the E&M code and ensure documentation clearly supports the unrelated nature of the visit. Reimbursement is based on 100% of the applicable fee schedule or contracted rate when requirements below are met. Failure to correctly use Modifier 24 or to document an unrelated diagnosis may result in denial, payment recoupment, or adjustment.

Append Modifier 24 to the appropriate level E&M service.
Document the reason for the E&M visit clearly in the member's medical record and office notes.
Use a diagnosis code unrelated to the original procedure for the E&M service.
Follow standard correct coding and billing guidelines; use industry-standard CPT/HCPCS/Revenue codes.
Noncompliance may lead to claim denial, payment recoupment/recovery, or reimbursement adjustment.

Definitions

Modifier 24

DefinitionModifier 24 — Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Healthcare Professional During a Postoperative Period

PurposeIndicates the same physician or qualified professional performed an E&M service during the postoperative period for a reason unrelated to the original procedure

Typical global package noteE&M services during the postoperative period usually are considered part of the global surgical package unless modifier 24 criteria are met

Billing requirementThe appropriate level of E&M service must be billed and appended with Modifier 24 for separate reimbursement