CurrentPremera BluecrossPolicy N/A

Modifier 24 — Unrelated Evaluation & Management Service in the Post-Operative Period

Defines when Premera recognizes CPT Modifier 24 for evaluation and management (E&M) or eye exam services provided by the same physician during the postoperative global surgical period; applies to Premera and affiliated lines of business and products.

Policy Summary

PayerPremera Bluecross

PolicyModifier 24 — Unrelated Evaluation & Management Service in the Post-Operative Period

Policy CodePolicy N/A

Change TypeAnnual reviewno material changes

Effective DateN/A

Next Review DateFeb 4, 2025

Key ActionAppend Modifier 24 to an E&M or eye exam code only when documentation shows the service was unrelated to the original surgical procedure and occurred during the postoperative global period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10- or 90-dayglobal period durations

All linesscope

Payment Integrity Oversight Committeereview history

Examples addedpolicy history

Modifier 24 — Coverage Criteria

Modifier 24 coverage criteria and exclusions

Conditions under which Modifier 24 is recognized and when it is not appropriate:

Modifier 24 may be appended when an unrelated E&M or eye examination is provided during the postoperative global surgical period (10- or 90-day) by the same physician or other qualified healthcare professional as determined by provider Taxonomy/Tax ID.

The diagnosis code submitted with the E&M or eye examination must clearly indicate that the service was unrelated to the original surgical procedure.

Exclusions — do not append Modifier 24 for any of the following:

Surgical complications or infections that do not require a return to the operating room.
Removal of sutures or other wound treatments that are considered part of the global surgical package.

Policy Summary

PayerPremera Bluecross

PolicyModifier 24 — Unrelated Evaluation & Management Service in the Post-Operative Period

Policy CodePolicy N/A

Change TypeAnnual reviewno material changes

Effective DateN/A

Next Review DateFeb 4, 2025

Key ActionAppend Modifier 24 to an E&M or eye exam code only when documentation shows the service was unrelated to the original surgical procedure and occurred during the postoperative global period.

SourceLink

On This Page

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Coding and Documentation

ModifierModifierCovered

Modifier 24

Unrelated E&M by same physician during postoperative period

ExclusionsmixedNot Covered

Examples of services where Modifier 24 should not be appended (surgical complications not requiring return to the operating room, suture removal/wound treatment, same-day surgical services, routine postoperative exams, services outside the global period)

Documentation requirement

Required documentationMedical record must clearly document that the E&M or eye exam was unrelated to the original surgical procedure

Diagnosis codingDiagnosis code submitted with the E&M or eye exam during the postoperative global surgical period should clearly show unrelatedness to the original surgery

Record sufficiencyServices submitted with Modifier 24 must be sufficiently documented in the member's medical record to establish unrelatedness

Provider identificationUnrelatedness determination tied to same physician or qualified healthcare professional as identified by provider Taxonomy/Tax ID number

Definitions and Inclusions

Definition — Modifier 24

TermUnrelated Evaluation & Management Service by the Same Physician in the Post-Operative Period (Modifier 24)

When usedAppended to an E&M or eye examination code to indicate an unrelated E&M service provided by the same physician or other qualified healthcare professional during the postoperative global surgical period (10- or 90-day)

Provider determinationApplicability is based on provider Taxonomy/Tax ID number to identify the same physician or qualified healthcare professional

Global surgical package — included services

Included servicesRoutine postoperative care (e.g., suture removal, wound treatment, routine postoperative exams) are considered part of the global surgical package and are not eligible for Modifier 24

Surgical complicationsSurgical complications or infections that do not require return to the operating room are considered part of the global surgical package and Modifier 24 should not be appended

Same-day servicesServices rendered on the same date as the surgical procedure are part of the global package and not eligible for Modifier 24

OpenPayer

Modifier 24 — Unrelated Evaluation & Management Service in the Post-Operative Period

Modifier 24 — Coverage Criteria

Coding and Documentation

Billing and Provider Actions

Definitions and Inclusions