AR2728
Expert
I, again, have questions regarding billing during global period.
Patient had lab chole performed 5/2/14--was observation status and discharge date is 5/3/14. Physician wants to bill a visit for 5/3/14 for leg cramps and gerd. The leg cramps are clearly unrelated (however, resolved when the physician rounded on 5/3-they occurred the previous evening)-the gerd is a ongoing issue for the patient for which he has remained on pepcid with no complaints of having any issues. I've attached the following documentation from the note that would be considered unrelated to normal global care--I did not attach the completed note as the majority was normal visit care following lap chole with dc instructions given. My issue with this how to capture this with an E&M since this occurred the same day as discharge and would be included. Am I able to bill a sub observation E&M even though this occurred on d/c day since I will not be billing a 99238. I need an outside opinion as I tend to be a bit judgemental where this physician is concerned, due to the high volume of patients he believes to be outside of global.
SUBJECTIVE: The patient did have some spasms and cramps in his legs last night. He has had these before after exercise. These have completely resolved. He is eating well. His pain is well controlled. He is having no fever, chills, nausea, vomiting, bloating, belching or heartburn. He has been passing flatus.
HE PERFORMED A COMPLETE EXAM-NORMALLY DOES. THEREFORE, I DID NOT ATTACHED.
ASSESSMENT AND PLAN: The patient does have episodes of heartburn and reflux but is currently on Pepcid and is having no symptoms. His pain is well controlled. He did have some leg cramps which he has had in the past but CK was normal.
Patient had lab chole performed 5/2/14--was observation status and discharge date is 5/3/14. Physician wants to bill a visit for 5/3/14 for leg cramps and gerd. The leg cramps are clearly unrelated (however, resolved when the physician rounded on 5/3-they occurred the previous evening)-the gerd is a ongoing issue for the patient for which he has remained on pepcid with no complaints of having any issues. I've attached the following documentation from the note that would be considered unrelated to normal global care--I did not attach the completed note as the majority was normal visit care following lap chole with dc instructions given. My issue with this how to capture this with an E&M since this occurred the same day as discharge and would be included. Am I able to bill a sub observation E&M even though this occurred on d/c day since I will not be billing a 99238. I need an outside opinion as I tend to be a bit judgemental where this physician is concerned, due to the high volume of patients he believes to be outside of global.
SUBJECTIVE: The patient did have some spasms and cramps in his legs last night. He has had these before after exercise. These have completely resolved. He is eating well. His pain is well controlled. He is having no fever, chills, nausea, vomiting, bloating, belching or heartburn. He has been passing flatus.
HE PERFORMED A COMPLETE EXAM-NORMALLY DOES. THEREFORE, I DID NOT ATTACHED.
ASSESSMENT AND PLAN: The patient does have episodes of heartburn and reflux but is currently on Pepcid and is having no symptoms. His pain is well controlled. He did have some leg cramps which he has had in the past but CK was normal.
