This document discusses modifiers 24 and 78 and how to determine if an evaluation and management (E/M) service provided during the global period of a procedure is unrelated or for complications. Modifier 24 is used if the E/M service is for an unrelated problem, while modifier 78 is used if the provider must return the patient to the operating room during the global period to treat complications. The definitions of unrelated may differ between payers, so providers need to check individual payer rules. Examples are given to illustrate the appropriate use of these modifiers.

1. MODIFIERS 24 &78

2. Modifier 24: How to Determine if an E/M
Service Is “Unrelated”
Payer rules differ with what’s considered an unrelated E/M service provided during the
global period of a procedure. Typically, an evaluation and management (E/M) service
provided during the global period of a procedure is not separately reimbursed, but is
bundled into payment for the procedure. An exception occurs when the E/M service is
unrelated to the procedure. The challenge is knowing how individual payers define
“unrelated.”
Source : AAPC

3. Identify Your Payer Rules
According to the Centers for Medicare & Medicaid Services (CMS), an E/M service
provided during the global period of a procedure is unrelated if:
 The E/M service is for treatment of a problem unrelated to the surgery
 The E/M service is for treatment of the underlying condition that prompted the
procedure
CMS considers E/M services for pain control and wound care to be related postoperative
care, as is any complication that doesn’t require a return to the operating room (OR)
(more on this, below).
The CPT® codebook likewise defines an unrelated E/M service as occurring for
treatment of a problem unrelated to the surgery or for treatment of the underlying
condition that prompted the procedure; but, unlike CMS, CPT® allows that a separately-
billable E/M service may be warranted for wound care, pain management, or treatment
of complications of surgery.
Source : AAPC

4. Example 1: A patient presents for a 30-day follow up after hip replacement. At that visit,
the patient complains of a new onset of shoulder pain. The provider documents the
elements of an E/M service to evaluate and treat the shoulder pain. Under both CPT®
and CMS guidelines, this E/M service is unrelated to the previous procedure because the
shoulder pain is not connected to the hip replacement.
Example 2: A patient presents for a 30-day follow up after hip replacement and
complains of pain, swelling, and discharge at the site of the hip replacement. The
provider documents the elements of an E/M service to evaluate and treat this
complication. Under CPT® rules, the E/M service is “unrelated” to the hip replacement.
Under CMS rules, the E/M service is related to the hip replacement because it is for
treatment of a complication of the previous procedure, and is not separately reimbursed.
Source : AAPC

5. Example 3: A patient undergoes breast biopsy (e.g., 19101 Biopsy of breast: open,
incisional). The results reveal malignancy, and the patient returns within the 10-day
global period to discuss treatment options. The provider documents the required
elements of an E/M service. Under both CMS and CPT® guidelines, this E/M is
“unrelated” to the previous biopsy because it is for treatment of the underlying
condition that prompted the biopsy.
Medicare and Medicaid payers follow CMS guidelines. For all other payers, it’s up to you
to determine which guidelines to follow.
Source : AAPC

6. Appending Modifier 24
To alert the payer that an E/M service provided during the global period is unrelated to
the previous procedure, you must append modifier 24 Unrelated evaluation and
management service by the same physician or other qualified healthcare professional
during a postoperative period.
Let’s return to Example 1 and assume the provider documented a level 3, established,
outpatient visit to evaluate the patient’s shoulder pain during the postoperative period
of a hip replacement. In this case, appropriate coding is 99213-24 Office or other
outpatient visit for the evaluation and management of an established patient, which
requires at least 2 of these 3 key components: An expanded problem focused history; An
expanded problem focused examination; Medical decision making of low complexity.
Remember: The definition of an “unrelated” (and thus, separately billable) E/M service
may differ, depending on the payer, as previously explained.
Source : AAPC

7. Modifier 78 for Complications Treated in the OR
If a provider returns a patient to the OR to treat complications during the global period,
you may report the treatment separately by appending modifier 78 Return to the
operating room for a related procedure during the postoperative period to the appropriate
CPT® code. The rule applies regardless of payer.
Let’s return to Example 2 and assume the provider must return the patient to the OR
during the global period to excise infected tissue at the incision site of the hip
replacement. In this case, report the appropriate debridement code (e.g.,
11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface)
with modifier 78 appended.
Source : AAPC