Wiki Post op or not?

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michelle24

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I don't know why my brain is not working today so I'm asking for a little help on this one.

Pt. was seen on 1/11/13 for a proctocolectomy (90 day global).

He comes back on 3/13/13 complaining of perineal pelvic pressure & dysuria.

A & P: Pouchoscopy (flexible sigmoidoscopy) performed in clinic shows no dehiscence & no pouchitis. Continue Cipro & Flagyl x 7 additional days.

Is the E/M or scope billable?

I don't think so because it's still in the Global Period. No new issues were discovered. The scope was done in the clinic (minor procedure room which is included in the global)

Any thoughts or suggestions are much appreciated.
 
I agree with your thinking. I dont think that an E&M would be billable in this case because the symptoms are or could be directly related to his surgery.
 
Scope is billable / E&M is not

The global period covers E/M services performed in the global period.
Additional,medically necessary, procedures are not covered under the global (except for obvious things like suture removal or removal of drains placed during surgery).

So bill the scope. Do not bill any E/M.

Hope that helps.
F Tessa Bartels, CPC, CEMC
 
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