E/M Coding Alert - 2014 Issue 5
Reader Question: Surgeon Decides Separate E/M During Global
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Article Overview
This reader Q&A explains the documentation and review considerations involved when an E/M service occurs during a global surgical period. It is aimed at coding professionals who need to understand how surgeons’ documentation affects whether a post-operative visit may be considered part of the surgery or a separately reportable service. The article discusses broad questions of relationship to the procedure, post-operative status, and how the physician’s impression affects coding review.
Why This Topic Matters
Global-period E/M decisions affect whether a post-operative encounter is bundled with surgery or may be reported separately, which directly impacts compliant billing and claim accuracy.
What You Will Learn
- How to approach E/M services that occur during a surgical global period
- Why physician documentation is central to determining whether a visit is related to the surgery
- How post-operative findings and disease-related issues are considered at a high level
- When to seek clarification from the surgeon before coding
Who Should Read This
- Professional coders
- Billing staff
- Compliance teams
- Physician documentation reviewers
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