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 in medical terms refers to the time period before and after a surgical procedure during which all related services and follow-up care are included in the initial payment made to the healthcare provider.
In simpler terms, it's like a package deal. When a patient undergoes surgery, the payment made to the doctor or hospital covers not only the surgery itself but also any visits, consultations, or care related to that surgery for a certain period, usually defined as the global period.
For example, if you have surgery with a 10-day global period, any follow-up visits or care needed within those 10 days are typically included in the initial payment. You won't be billed separately for those services during that time frame.
This concept helps simplify billing and payment for both patients and healthcare providers by bundling related services together for a specific period after a surgery.
The Global Surgical Package is decided based on the type of procedure performed: simple, minor, or major.
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.
Report 1
Patient Name: John Doe
Date of Service: 09/11/2024
Chief Complaint: Laceration on left forearm after a fall
History of Present Illness:
The patient presents with a 3 cm laceration on the left forearm that occurred 2 hours ago. The wound is jagged, and the patient reports moderate pain. No signs of infection or foreign bodies. The patient denies any previous incidents like this or significant medical history related to bleeding disorders. The patient had an updated tetanus shot within the last 3 years.Review of Systems: Denies any headache, dizziness, or other systemic complaints.
Physical Exam:
The patient is alert and oriented, no distress. The laceration is on the left forearm, measuring 3 cm, and extends through the dermis. There is mild bleeding. The surrounding skin shows no signs of infection. Neurological and cardiovascular exams are within normal limits.Medical Decision Making (MDM):
The decision was made to repair the laceration. Moderate complexity of care was required, considering the need for local anesthesia and layered closure. The patient was advised about the procedure, potential complications, and care after the repair. Consent was obtained.Procedure:
The area was cleaned and anesthetized using 1% lidocaine. A 2-layer closure was performed with 4-0 Vicryl for the deep layer and 5-0 nylon for the outer skin layer. The wound was dressed with sterile gauze. Post-procedure care instructions were given, including keeping the area clean and dry, monitoring for signs of infection, and follow-up in 10 days for suture removal.Assessment/Plan:
Laceration repair.
Instructions on wound care and follow-up provided.
Report 2:
Patient Name: Jane Smith
Date of Service: 09/11/2024
Chief Complaint: Laceration on the right hand
History of Present Illness:
The patient presents with a 4 cm laceration on the right hand sustained during cooking. No signs of infection or foreign bodies.Physical Exam:
The laceration is on the dorsal aspect of the right hand, measuring 4 cm, with mild bleeding and clean edges. The surrounding skin shows no signs of infection.Procedure:
The area was cleaned and anesthetized with 1% lidocaine. The laceration was closed in a single layer using 5-0 nylon sutures. The wound was dressed, and the patient was advised on post-procedure care.Assessment/Plan:
Laceration repair.
Report 1: The provider performed and documented a separately identifiable E/M service. The E/M service involved the evaluation of the patient's condition, moderate MDM, and a decision on how to manage the laceration. This qualifies for billing both the E/M code (99214) with modifier -25 and the procedure code (12032).
Report 2: Here, the provider only addressed the procedure of laceration repair, with no significant evaluation or management beyond the procedure. Therefore, only the procedure code (12032) is billed.