Bill an E/M for This Follow-Up Situation
Question: A provider saw a patient and performed a procedure, which had 0 global days, and then awaited findings from pathology. When the findings came back, the results indicated that the tissue analyzed was benign and the provider documented that the problem the patient was being seen for was resolved. If the patient’s issue started again and they came back for a follow-up visit, could we bill an evaluation and management (E/M) service like 99212 for the encounter? AAPC Forum Participant Answer: If a procedure has a global period of 0 days, then you should feel empowered to bill an E/M service like 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.) for a follow-up visit. As long as the provider records sufficient documentation to support the E/M level and visit, then it would be appropriate to report and bill such a visit accordingly. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
