What constitutes proper pre- and postoperative documentation for global billing?

• A. Document preop evaluation, plan, informed consent, postop instructions, and any complications; ensure date alignment.
• B. Only the preop consent is required; post-op instructions are optional.
• C. Documentation is not required for global billing.
• D. Only the final postoperative diagnosis is needed.

Answer: (B)

Global billing for a surgical procedure relies on a complete record of the entire perioperative care. The chart should clearly show the preoperative evaluation and plan, informed consent, postoperative instructions, and any complications, with dates that align to the procedure date. This documentation demonstrates that the care encompassed by the global period was planned, consented to, and carried out, including the guidance given to the patient after surgery and any issues that arose.

Simply documenting only the preoperative consent leaves out essential elements of the bundled care, and that incomplete record can undermine the justification for the global payment. Postoperative instructions are not optional components; they are part of the postoperative care that the payer expects within the global period. Documenting only the final postoperative diagnosis fails to capture the full sequence of preop planning, patient consent, and the instructions provided after surgery, which are all necessary to support global billing. Ensure each part is present and dated to reflect its relation to the procedure.