Medicare denial of 99214 the day before a 21930 performed

A Medicare patient came in on a monday for his routine 3 mo check for 401.1 and 250.00.(99214) The following day he came in to have an excision of a growth on his back (in office)99213-25 and 21930-59. The 99214 on monday was denied as pre-op even though the icd9 codes had nothing to do with his growth just 401.1 and 250.00. Medicare appeals said we should have used a modifier with the 99214 to designate it as pre op. Which modifier? It wasn't a pre op PE. He just happened to have his routine 3 month check up the day before the procedure.

re: Medicare denial of 99214 the day before a 21930 performed

Medicare denied the ov as per Medicare guidelines, the global period begins 1 day prior to the surgical encounter. If a decision for surgery was made the day prior at the time of the ov, you need to append modifier -57 to warrant payment of the ov.

Components of a Global Surgical Package (Cahaba)

Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;

Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical procedure;

Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;
Postoperative Visits - Follow-up visits during the postoperative period of the surgery that is related to recovery from the surgery;

Postsurgical Pain Management - By the surgeon;

Supplies - Except for those identified as exclusions; and

Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

re: Medicare denial of 99214 the day before a 21930 performed

Sorry, I did not read this correctly, I would append modifier -24 to the ov 99214. Modifier- 24 unrelated to procedure or service within a global period.

re: Medicare denial of 99214 the day before a 21930 performed

Thank you! Very helpful!

re: Medicare denial of 99214 the day before a 21930 performed

Looks like -24 is best choice, in this case.

re: Medicare denial of 99214 the day before a 21930 performed

My modifier list states 24 is unrelated E/M service by same physician during a post-op period. The denied 99214 was the day BEFORE the surgical procedure. Would 24 work?

re: Medicare denial of 99214 the day before a 21930 performed

Yes, modifier -24 will work and is apporpiate. Your 90 day global period began (1) day prior to the performance of CPT® 21930. Therefore by appending modifier -24 on your ov (99214) you carve it out of the global package.

re: Medicare denial of 99214 the day before a 21930 performed

Thanks! Like the old adage "you learn something new every day!!

re: Medicare denial of 99214 the day before a 21930 performed

So true!