tci General Surgery Coding Alert - 2014 Issue 5

Reader Question: Surgeon Decides Separate E/M During Global

Question: Our surgeon performed an ileostomy revision, and the patient was returned five days later complaining of weakness. The surgeon evaluated the stoma, and stated that his impression was Crohn’s and post-surgical inflammation of the stoma. As a coder, how can I decide if an E/M service provided in the global period is separately billable?  Texas Subscriber Answer: As a coder, you can’t make the decision for a separate E/M during the global surgical period. The physician must document whether the E/M service is related to the surgery. Based on the information you’ve given, it&rsquo...

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