Global period & EM Modifier

In the realm of medical billing, the global period serves as a key factor in determining which E/M modifiers are appropriate. E/M modifiers like 25, 57, and 24 are selected based on the global period associated with the procedures or services billed alongside E/M services.

Modifier 25 comes into play when an E/M service is performed on the same day as another procedure. It indicates that the E/M service was separate and distinct from the other service provided, justifying separate reimbursement.

Modifier 57, on the other hand, is used when an E/M service results in the decision to perform surgery. This modifier highlights the significant role of the E/M service in the decision-making process for surgery, particularly when performed during the global period of a previous procedure. For Modifier 57, it is important to note that it is appended for major surgery, which typically has a global period of 90 days. The modifier is defined by the decision for surgery, and while it may seem obvious that a decision is required for every major surgery, it serves as a formal indicator of this critical decision-making process. No major surgery can be performed without the decision being made and documented, underscoring the importance of this modifier in the billing process.

Modifier 24 is used to indicate that an E/M service is unrelated to a previous procedure during the global period. It signifies that the E/M service is for a different reason and should be reimbursed separately.

Understanding these nuances is crucial for accurate billing and reimbursement, ensuring that providers are properly compensated for their services.

What is Global period?

The global period refers to the time before and after a surgical procedure during which all related services and follow-up care are included in the initial payment to the healthcare provider.

Think of it as a "package deal" for surgery. When you undergo surgery, the payment made to the doctor or hospital covers not just the surgery itself but also any related visits, consultations, and care during a defined period after the surgery. For instance, if you have surgery with a 10-day global period, any follow-up care within those 10 days is already included in the payment. This means you won't receive additional bills for these services within that time.

This approach simplifies billing for both patients and healthcare providers by bundling all related services into one payment.

The Global Surgical Package depends on the type of procedure—whether it’s a minor, major, or simple surgery. The package includes various services such as:

1. Pre-Operative Evaluation: Evaluation and Management (E/M) services provided before surgery, such as medical history and physical exams on the day or day before surgery.

2. Anesthesia: Local or topical anesthesia services required for the surgery.

3. Post-Operative Care: Immediate care after surgery, including documentation, discussions with the family, and coordination with other healthcare professionals.

4. Writing Orders: Any medical orders that are necessary for the patient's care after surgery.

5. Post-Anesthesia Recovery Evaluation: The surgeon's assessment of the patient’s recovery after anesthesia.

6. Follow-Up Care: Routine postoperative visits to check on the patient’s recovery.

By covering all these services under one payment, the global surgical package reduces the complexity of billing for patients and medical professionals alike.

Modifier 25 is appended:

• Postop period (Global period) is 0 day or 10 days.

• Surgery or service happened on same day of the EM.

Modifier 57 is appended:

• Postop period (Global period) is 90 days.

• Surgery or service happened on same day or next day of the EM.

Modifier 24:

Modifier 24 is used during the postoperative period (within the 10 or 90-day), which is the period following a surgical procedure.

when the patient returns for an E/M service that is unrelated to the original surgery. This means that the patient has a new or different medical issue that requires evaluation and management, and it is not a routine follow-up related to the surgery itself. Then to bill the EM, coder must assign 24 modifier.

Example: A new patient visited the clinic today with a complaint of an abscess on their back. The physician conducted a comprehensive evaluation and management (E&M) for which a moderate level of medical decision-making (MDM) was necessary. Subsequently, the physician performed an incision to drain the abscess, and an operative note was documented to support the code 10060.

The visit that took place on Jan 1 is coded as 99204-25, 10060.

On Jan 5, the patient returned for a related complaint or to have their Jan 1 procedure evaluated. This visit falls within the global period and is related to the original procedure, so it is bundled into the global surgical package and coded as 99024 (Postoperative follow-up visit). This code indicates that an E&M service was performed during the postoperative period for reasons related to the original procedure.

On Jan 7, the patient returned with a complaint of abdominal pain. The physician performed an evaluation and management (E&M) with a moderate level of medical decision-making (MDM). This visit should be coded as 99214-24.

The addition of the "-24" modifier indicates that the patient is returning within the global period but for unrelated reasons. If this modifier is omitted, the visit may be considered bundled, and the payer may not reimburse it.

Note:

99024: Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.

Modifier 25 is Definition:

25 Modifier: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service..

Modifier 57 is Definition:

• Decision for Surgery

• An Evaluation and Management service is added with 57 Modifier when it results into decision of performing of manor procedure (has 90 days global period). The surgery must be performed within 24 hours after taking the decision.