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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyWellpoint Modifier 24 Policy Update | OpenPayer
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    CurrentWellpointPolicy G-06011

    Modifier 24

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    Reimbursement for evaluation and management services billed with modifier 24 during the postoperative period of an original procedure in Iowa.

    Policy Summary
    PayerWellpoint
    PolicyModifier 24
    Policy CodePolicy G-06011
    Change TypeNonmaterial policy revision
    Effective DateJune 11, 2025
    Next Review DateN/A
    Key ActionBill the appropriate level of E/M service with modifier 24 when the service is performed during the postoperative period for a reason unrelated to the original procedure.
    SourceLink
    POLICY UPDATE CHANGES

    The policy statement was revised to remove the word "limited."

    The Definitions section was updated.

    The policy title and related policies section were updated, with minor language and formatting changes.

    100%Reimbursement rate for qualifying E/M services
    3Required qualification criteria
    24Modifier for unrelated postoperative E/M service
    1Unrelated diagnosis requirement

    Modifier 24 Reimbursement Criteria

    Modifier 24 reimbursement criteria

    Reimbursement is available when all of the following criteria are met:

    ALL of the following

    • The appropriate level of evaluation and management (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.
    Qualifying services are reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate.

    Modifier 24 Coding

    Policy Summary
    PayerWellpoint
    PolicyModifier 24
    Policy CodePolicy G-06011
    Change TypeNonmaterial policy revision
    Effective DateJune 11, 2025
    Next Review DateN/A
    Key ActionBill the appropriate level of E/M service with modifier 24 when the service is performed during the postoperative period for a reason unrelated to the original procedure.
    SourceLink
    On This Page
    Modifier 24 Reimbursement CriteriaModifier 24 CodingBilling and Documentation RequirementsPolicy Definitions

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Modifier 24Modifier
    24Modifier 24 indicates an unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period.

    Billing and Documentation Requirements

    Billing Rule

    Append Modifier 24

    Bill the appropriate level of Evaluation and Management (E/M) service during the postoperative period for an unrelated reason, and append modifier 24 to the claim.

    Documentation Required

    Document the Unrelated E/M Service

    Support the unrelated postoperative E/M service with an unrelated diagnosis code and clearly document the reason for the E/M service in the member's medical record.

    Denial Risk

    Incorrect Modifier Use Risks Denial and Recoupment

    Failure to use modifier 24 correctly may result in denial of the E/M service. Claim payments may also be recovered or recouped.

    Policy Definitions

    Modifier 24
    DefinitionAn unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period.
    When it appliesThe physician or other qualified healthcare professional needed to perform the E/M service during the postoperative period for a reason unrelated to the original procedure.
    How to reportAdd modifier 24 to the appropriate level of E/M service.
    General Reimbursement Policy Definitions
    Applicable definitionsGeneral reimbursement policy definitions apply.
    PolicyReimbursement Policy Modifier 24.
    Policy numberG-06011.