Proper documentation is critical to justifying medical necessity and the selection of codes for billing. It tells the story of a patient visit by recording pertinent facts, findings, and observations. Payers will use this documentation to verify coding choices, site of service, medical necessity, appropriateness, and accurate reporting of furnished services. Each office note must tell a complete story and be able to stand alone.
The global surgical package, also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the preoperative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.