Unrelated Evaluation and Management during a Postoperative Period

E/M serviceTypical post-operative care, including related evaluation and management is not separately reportable; but, an unrelated evaluation and management service during a postoperative period may be.

According to the Centers for Medicare and 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 (more on this, below).

Unlike CMS, The CPT® manual allows that a separately-billable E/M service may be warranted for wound care, pain management, or treatment of complications of surgery.

For example, a patient presents for 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 a complication of the previous procedure, and is not separately reimbursed.

Appending Modifiers 24 and 78:

To alert the payer of a separately-billable, unrelated evaluation and management service during a postoperative period , you must append modifier 24 Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period appended.

If a provider returns a patient to the operating room 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.

To return to our example, above, assume that the provider must return the patient to the operating room 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.

Reporting Related E/M Services During Global:

You may report related E/M services during the global period with 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. There is no reimbursement value associated with the code.

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