What are the rules for modifier 24?
Asked by: Korey Parker | Last update: December 8, 2025Score: 4.9/5 (32 votes)
What is an example of inappropriate use of modifier 24?
Inappropriate use: It would be inappropriate to report an E/M code with Modifier 24 for routine postoperative care or for managing a surgical complication such as infection, removal of sutures, or other wound treatment, as these treatments are already part of the surgery package and have been “prepaid.” For example, if ...
When to use modifier 24 and 25 together?
You can use modifiers 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) and 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the ...
What does code 24 mean in a hospital?
Inadequate documentation: Proper documentation is crucial for accurate billing and reimbursement. If the healthcare provider fails to provide sufficient documentation to support the charges or if the documentation is incomplete or illegible, the claim may be denied with code 24.
What is cpt code 99213 with modifier 24?
In this case, the coder correctly assigns the CPT code 99213-24 for the office outpatient visit of an established patient, including an expanded problem-focused history, an expanded problem-focused physical exam, and medical decision-making of low complexity.
MODIFIER 24 FOR EVALUATION AND MANAGEMENT EXPLAINED MEDICAL CODING
What is the modifier 24 for billing guidelines?
Use Modifier 24 on an E/M when: An unrelated E/M service is performed beginning the day after the procedure, by the same physician, during the 10 or 90-day post-operative period. Documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care.
What are the rules for CPT code 99213?
What is CPT code 99213 used for? CPT code 99213 is used for an established patient office or other outpatient visit that requires a medically appropriate history and/or examination and low level of medical decision-making along with 20 minutes of encounter time.
What is the point of service code 24?
A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis. Special Considerations: When a physician/practitioner furnishes services to a patient in a Medicare-participating ambulatory surgical center (ASC), the POS code 24 (ASC) shall be used.
What is denial reason code 24?
Lack of prior authorization: Some services require prior authorization from the managed care plan before they can be performed or reimbursed. If the provider fails to obtain the necessary authorization or if the authorization is not properly documented, the claim may be denied with code 24.
What does occurrence code 24 mean?
AN OCCURRENCE CODE 24 IS PRESENT ON THE CLAIM; HOWEVER, NO VALUE CODE IS PRESENT OR YOU ARE BILLING FOR A MEDICARE PRIMARY PAYMENT. THERE IS AN OCCURRENCE CODE 24 ON THE CLAIM AND YOUR REMARKS DO NOT SUFFICIENTLY EXPLAIN WHY THE PRIMARY INSURER DID NOT PAY THIS CLAIM.
How do I know which modifier to use?
The correct modifier to use is determined by payor preference. There can be instances where a CPT code is further defined by an HCPCS modifier, for example, to describe the side of the body the procedure is performed on, such as left (modifier -LT) or right (modifier -RT).
What is the modifier 25 rule?
Modifier 25 should be appended to the office or other outpatient visit code to indicate that a significant, separately identifiable E/M service was provided on the same date as the preventive medicine E/M service, and the appropriate preventive medicine E/M service is additionally reported without a modifier.
What is the difference between modifier 24 and 57?
Modifier -57 would be appended for a major procedure and modifier -25 for a minor procedure (some insurance programs allow both modifiers to be appended). Modifier -24 is only used when the care provided during the global post time period is for a clearly documented unrelated visit.
What is the separate procedure rule?
6. CPT “Separate procedure” definition: The narrative for many HCPCS/CPT codes includes a parenthetical statement that the procedure represents a "separate procedure". The inclusion of this statement indicates that the procedure can be performed separately but should not be reported when a related service is performed.
What is the postoperative period?
The postoperative period includes the time from the end of the procedure in the operating room until the woman has resumed her normal routine and lifestyle. Postoperative complications may occur at any time; however, early recognition and management will often preclude larger problems.
How to tell if CPT codes are bundled?
This depends on medical coding rules. Bundling occurs when procedures or services with unique CPT or HCPCS Level II codes are billed together under one code. Unbundling is when two or more codes that are normally part of a single procedure can be billed separately.
What is adjustment reason code 24?
The CO 24 denial code is used to indicate that the claim made has been denied due to the patient's insurance coverage under a capitation agreement or a managed care plan.
What is denial reason 25?
What is Denial Code N25. Remark code N25 indicates that the payer processing the claim is only responsible for the administrative aspects of claims payment services. This entity does not carry any financial risk or obligation for the claims it processes on behalf of the benefit plan.
What is a major medical adjustment?
Denial code 102 is a Major Medical Adjustment that indicates a claim has been denied or adjusted due to a significant medical reason.
What is modifier 24?
Modifier 24 is intended for use with services that are absolutely unrelated to the surgery; it is not intended to be used for the medical management of a patient by the surgeon following surgery.
What is the problem code 24?
(Code 24)" The device is installed incorrectly. The problem could be a hardware failure, or a new driver might be needed.
What is reason code 24?
CO 24 denial code refers to "denied miscellaneous payments." It signifies that the billed service or procedure is uninsurable, non-covered, or not payable under the patient's insurance plan. This denial code can result from various reasons, including incorrect coding, lack of medical necessity, and policy exclusions.
What modifier should be used with 99213?
If the E/M is not bundled into the stress test, then the Cardiologist's coder can use modifier 25 to indicate that these two services were separate and significant: 99213-25, 93015.
How many minutes is a 99214?
CPT® code 99214: Established patient office visit, 30-39 minutes | American Medical Association.
What are the changes in E&M coding for 2024?
Office/outpatient Evaluation and Management (E/M) coding changes for 2024. Office/outpatient visit E/M time-based coding will change in 2024 to align with other E/M codes. Time ranges will be omitted and replaced with base time to meet or exceed.