Based on widespread probes of office evaluation and management (E/M) services, First Coast has discovered that the 24 modifier for E/M services, when billing within a global surgery period, has been billed incorrectly at least 60 percent of the time. Clinical review of documentation demonstrates that modifier 24 was either not supported for the encounter, or was improperly applied (i.e., a different modifier should have been submitted).
To address this widespread improper billing, First Coast implemented a pre-payment edit on April 16, 2012, applicable to office visit E/M claims (codes 99201-99205 and 99212-99215) billed with the 24 modifier.
Claims
For claims containing modifier 24 received on or after April 16, 2012, First Coast began developing to the provider to provide supporting documentation that justifies the use of the 24 modifier. Providers must respond within the specified timeframe included in the development letter. Failure to submit the documentation timely may result in a claim denial.
Reopenings
Also effective April 16, 2012, First Coast no longer accepts:
• Telephone requests via the interactive voice response or a customer service representative to add or change the 24 modifier on a previously denied claim.
• Written or fax requests (processed on or after April 16) to add or change the 24 modifier without supporting documentation. The provider will be sent a written notification that their request could not be completed.
Carriers pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT modifier “-24,” and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure. They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.
How to use modifiers to indicate the status of an ABNIf a provider or supplier expects that the service or item furnished to the beneficiary may be considered unreasonable and/or medically unnecessary by Medicare, an advanced beneficiary notice (ABN) may be used to inform the beneficiary of his or her financial liability, appeal rights, and protections under the fee-for-service (FFS) Medicare program.
Providers and suppliers should use the appropriate modifier when submitting such claims to indicate whether they have or do not have an ABN signed by the beneficiary.
Modifier criteria:
• Modifier GZ — must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary, and they do not have an ABN signed by the beneficiary.
Note: Effective July 1, 2011, all claims line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review.
• Modifier GA — must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file.
Note: All claims not meeting medical necessity of a local coverage determination (LCD) must append the billed service with modifier GA or modifier GZ.
