# Visits during the Global Period



## AR2728 (Mar 14, 2013)

I'd like some feeback on visits during the global period.  I completely undertand and agree that if the patient has an issue *unrelated *to the procedure that is treated during the global period that an office visit for that unrealted issue shoud be billed.  However, here is an example of what I am seeing for one of my general surgeons-on a regular basis:

A hernia repair is performed on an established patient (in months prior to this the patient was being treated for gastritis diverticulosis and had an EGD/Colonoscopy performed and follow up visit for this).  The patient presents back to the office for his second follow up visit to colectomy.  A partial suture removal is done the CC lists _diverticulosis, hx colon polyps, gastritis, status post henia repair, morbid obesity, atelectasis ._.  The note goes into detail about presenting symptoms prior to surgery, hospital stay-atelectasis, and then mentions his hx of polyps, gastritis and diverticulosis current treatment and is stable.  
Assessment and Plan states 
1. postop follow up...postop restrictions and care
2. diverticulosis hx colon polyps continue regimen 
3. gastritis stable
4.atelectasis during hospital stay resolved (which was mentioned at the first follow up visit as well)

My surgoen wants to bill a separate E&M.  This is a frequent occurance.  He addresses issues that have previously been treated or are resolved, such as atelectasis or gastritis-when the reason for the visit was for suture removal or surgery follow up.  It is typical for him to continue to document these issues on every follow up visit during the global period-even though the previous visit stated the issue was resolved.  I have noticed this as a trend, he feels it is necessary to address all past history/conditions and then wants to justify billing a level.  I however, feel that just because he feels it is necessary to go into great detail and do a thorough review at EVERY global follow up visit, this does not justify billing an E&M.  I suppose my stance is ...what the patient is truly presenting for and what needs to be addressed...had the patient NOT had surgery would he have requested them to come back in 2 weeks for gastritis/diverticulosis only (for example).


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## nyyankees (Mar 14, 2013)

how is he treating, if at all, the non-hernia issues? If it becomes a trend this is where the doc can get into trouble. Almost like booking the last post-op visit on day 91 on a egular basis.


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## AR2728 (Mar 14, 2013)

My thoughts exactly.  As far as how he is treating the other issues, in most cases simply stating for them to remain on their current treatment.  He is notorious for repeating the recomendations he provided at the previous visit-no change to the current plan for that specific problem or new recomendations provided.  In fact, I see very few visits that he chooses 99024-global-these are always patients who have only seen him for the specific issue related to surgery. 

Another example I have seen recently was a patient being seen for global follow from surgery and they mention now that they have developed a new rash.  I agree this is a new issue and he provides treatment, so an E&M should be billed.  If he follows up on the unrelated rash-I agree the subsequent visit should also be billed with an E&M.  However, I will commonly see him continue to document the rash and want to bill an E&M even after the rash is resolved and has been resolved for some time and they are technically still following because of their original surgery.  

I'm looking for assistance now because they will be moving to an EMR.  I foresee him arguing with me and demanding proof that these visits should not be billed with E&M.  He also believes that an established comprehensive H&P justifies billing 99215-regardless of the MDM, and our EMR does not have the ability to make MDM one of the two components.  He is a very educated, top notch surgeon, but unfortunately not easily swayed when discussing coding guidelines and doucmentation. I have my work cut out for me and need to arm myself with solid documentation.  Any guidance and reference material will be GREATLY APPRECIATED.


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## Emmy1260 (Mar 15, 2013)

99024 "Postoperative follow-up visit,  ... for a reason(s) related to the original procedure." So anything related to the procedure, such as a hospital aquired condition or complication, would be included. 

One way to look at this is to separate the documentation to post op and e/m visits. When you start splitting the documentation up, as you cannot use the same info in both visits, you might find there isn't anything left for the second E/M. 

Sounds like you have your hands full with this one. Review the rules for E/M services, find lots of solid documentation from reliable sources and then talk with your physician. 

Another option is to send out some of his encouter documentation to a third party and have them review. We do this with new physician to our practice when their opinion does not agree with the coder's.


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## AR2728 (Mar 19, 2013)

Thanks Emmy1260.  I'm in a small rural area and the only certified coder on our campus between the hospital and physican offices.  I truly appreciate the feedback from other coders


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