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Global Surgery

This article is a summary of the CMS Publication (ICN 907166). To read the full publication, please go to https://www.cms.gov and in the search box enter the ICN 907166 and your first link should be the Global Surgery Fact Sheet.

Definition of a Global Surgical Package

The global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the preoperative, intra-operative and postoperative 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.

Where can I find the postoperative periods for covered surgical procedures?

The MPFS look-up tool provides information on each procedure code, including the global surgery indicator The payment rules for global surgical packages apply to procedure codes with global surgery indicators of 000, 010, 090 and sometimes YYY.

  • Codes with “000” are endoscopies or some minor surgical procedures (zero day postoperative period).
  • Codes with “010” are other minor procedures (10-day postoperative period).
  • Codes with “090” are major surgeries (90-day postoperative period).
  • Codes with “YYY” are contractor-priced codes, for which contractors determine the global period. The global period for these codes will be 0, 10, or 90 days. Note: not all contractor-priced codes have an “YYY” global surgical indicator. Sometimes the global period is specified as 000, 010, or 090.

While codes with “ZZZ” are surgical codes, they are add-on codes that you must bill with another service. There is no postoperative work included in the MPFS payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global period assigned is applied to the primary code.

What services are included in the global surgery payment?

When the physician who furnishes the surgery also furnishes the following services, Medicare includes them in the global surgery payment:

  • Preoperative visits after the decision is made to operate. For major procedures, this includes preoperative visits the day before the day of surgery. For minor procedures, this includes preoperative visits the day of surgery;
  • Intra-operative services that are normally a usual and necessary part of a surgical procedure;
  • All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications, which do not require additional trips to the operating room;
  • Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;
  • Post-surgical pain management by the surgeon;
  • Supplies, except for those identified as exclusions: and
  • Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

What services are not included in the global surgery payment?

The following services are not included in the global surgical payment. These services may be billed and paid for separately:

  • Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier 57 (Decision for Surgery). This visit may be billed separately only for major surgical procedures:

Note: The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier 25 is used to bill a separately identifiable E&M service by the same physician on the same day of the procedure.

  • Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;
  • Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
  • Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;
  • Diagnostic tests and procedures, including diagnostic radiological procedures;
  • Clearly distinct surgical procedures that occur during the postoperative period which are not reoperations or treatment for complications;

Note: A new postoperative period begins with the subsequent procedure. This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure.

  • Treatment for post-operative complications requiring a return trip to the operating room (OR). An OR, for this purpose, is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR);
  • If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;
  • Immunosuppressive therapy for organ transplants; and
  • Critical care services CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.

How are minor procedures and endoscopies handled?

Minor procedures and endoscopies have postoperative periods of 10 days or zero days (indicated by 010 or 000, respectively).

For 10-day postoperative period procedures, Medicare does not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the 10-day period, the major surgery is payable separately. Services by other physicians are generally not included in the global fee for minor procedures.

For zero day postoperative period procedures, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. Postoperative visits are separately billable and payable.

Using Modifiers 54 and 55

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:

  • Surgical care only (modifier 54); or
  • Postoperative management only (modifier 55).

For global surgery services billed with modifiers 54 or 55, the same CPT code must be billed. The same date of service and surgical procedure code should be reported on the bill for the surgical care only and postoperative care only. The date of service is the date the surgical procedure was furnished.

Modifier 54 indicates that the surgeon is relinquishing all or part of the postoperative care to a physician.

  • Modifier 54 does not apply to assistant-at-surgery services.
  • Modifier 54 does not apply to an ASC’s facility fees.

The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier 55.

  • Use modifier 55 with the CPT procedure code for global periods of 10 or 90 days.
  • Report the date of surgery as the date of service and indicate the date care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.
  • The receiving physician must provide at least one service before billing for any part of the postoperative care.
  • This modifier is not appropriate for assistant-at-surgery services or for ASC’s facility fees.

Exceptions to the Use of Modifiers 54 and 55

Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate E&M code. No modifiers are necessary on the claim.

Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E&M code, without a modifier.

If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports the appropriate E&M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.

E&M Service Resulting in the Initial Decision to Perform Surgery

E&M services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separately.

In addition to the CPT E&M code, modifier 57 (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery.

The modifier 57 is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure. Carriers/MACs may not pay for an E&M service billed with the CPT modifier 57 if it was provided on the day of or the day before a procedure with a 0- or 10-day global surgical period.

Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure

Modifier 25 (Significant, separately identifiable E&M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E&M service beyond the usual preoperative and postoperative care associated with the procedure or service.

  • Use modifier 25 with the appropriate level of E&M service.
  • Use modifiers 24 (Unrelated E&M service by the same physician during a postoperative period) and 25 when a significant, separately identifiable E&M service on the day of a procedure falls within the postoperative period of another unrelated, procedure.

Different diagnoses are not required for reporting the E&M service on the same date as the procedure or other service. Both the medically necessary E&M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.

Postoperative Period Billing

Unrelated Procedure or Service or E&M Service by the Same Physician During a Postoperative Period

Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the postoperative period of a surgical procedure, but not included in the payment for surgical procedure.

  • Modifier 79 (Unrelated procedure or service by the same physician during a postoperative period). The physician may need to indicate that a procedure or service furnished during a postoperative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.
  • Modifier 24 (Unrelated E&M service by the same physician during a post-operative period). The physician may need to indicate that an E&M service was furnished during the post-operative period of an unrelated procedure. An E&M service billed with modifier 24 must be accompanied by documentation that supports that the service is not related to the postoperative care of the procedure.

Return to the OR for a Related Procedure during the Postoperative Period

When treatment for complications requires a return trip to the operating room, physicians bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, use the unspecified procedure code in the correct series, i.e., 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.

In addition to the CPT code, physicians report modifier 78 (Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the postoperative period).

The physician may also need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first procedure, and requires the use of the operating room, this circumstance may be reported by adding the modifier 78 to the related procedure.

Note: The CPT definition for modifier 78 does not limit its use to treatment for complications.

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. Modifier 58 indicates that the performance of a procedure or service during the postoperative period was:

  • Planned prospectively or at the time of the original procedure;
  • More extensive than the original procedure; or
  • For therapy following a diagnostic surgical procedure.

Modifier 58 may be reported with the staged procedure’s CPT. A new postoperative period begins when the next procedure in the series is billed.

Critical Care

Critical care services furnished during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances.

Preoperative and postoperative critical care may be paid in addition to a global fee if:

  • The patient is critically ill and requires the constant attendance of the physician; and
  • The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed.

Such patients are potentially unstable or have conditions that could pose a significant threat to life or risk of prolonged impairment.

In order for these services to be paid, two reporting requirements must be met:

  • CPT codes 99291/99292 and modifier 25 for preoperative care or 24 for postoperative care must be used; and
  • Documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted. An ICD-10 code for a disease or separate injury which clearly indicates that the critical care was unrelated to the surgery is acceptable documentation.

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