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What Is The Global Surgical Package?

The global surgical package is a single payment for all care associated with a surgical procedure. The payment is based on three phases of a surgical procedure.

Other names for the Global Surgical Package include: Postoperative Period, Global Period, Global Services, Surgical Period, Global package and Global Surgery.

The Current Procedural Coding (CPT) manual, produced by the American Medical Association (AMA) gives an overview of the definition of the surgical package. This definition outlines what is considered incidental or included in the surgical package but doesn’t go into great detail. Because the Centers for Medicare and Medicaid has outlined a detailed description of what is considered incidental or included in the global surgical package and most insurance companies tend to follow the decisions made by Medicare, we will review and refer to their definition for this article.

Three Types of Procedures Have a Global Surgical Package

The three types of procedures that carry a global surgical package include simple, minor and major procedures.

1. Simple Procedures  (Zero Global Period)

   • There is no preoperative/postoperative period so the global period is only the day of the procedure.
   • Unless special circumstances exist, a visit on the same day as surgery is not payable.
   • Services are generally simple minor procedures and some endoscopic procedures.

2. Minor surgical procedures  (10-day global period)

   • There is no preoperative period so the global period starts the day of the procedure.
   • Unless special circumstances exist, a visit on the same day as surgery is not payable.
   • There are 11 days in the global surgical package beginning the day of the procedure and then the 10-days following it.

3. Major surgical procedures  (90-day global period)

   • There is one day of preoperative care so the global period starts the day prior to the surgery.
   • Care on the day of the surgery is included in the global period unless the decision to perform the surgery was made during the visit on this day. (See modifier -57).
   • There are 92 days in the global surgical period beginning the day before the procedure, the day of the procedure, and the 90 days following it.

Services provided to the patient preoperatively, intra-operatively and postoperatively are considered part of this global surgical package and are included in the cost of the surgery, whether rendered by the surgeon or by members of the same medical group within the same specialty.

Splitting the Global Surgical Package?

The global surgical package is made up of three parts:

1. Preoperative evaluation (8-12% of the global package)
2. Intra-operative procedure (70-80% of the global package)
3. Postoperative care (7-20% of the global package)

When a surgeon provides all three phases of the patient’s care for a surgical procedure the surgeon will bill the surgical procedure and receive payment for the entire global package.

In a case where the providers agree upon a transfer of care during the global period, a transfer of care document should follow the patient to the provider performing the postoperative service indicating the date of the transfer of care and this should remain on file in the patient’s record.

The surgical claim should report the procedure code, date of the procedure and the appropriate modifier:

Modifier -54: Surgical Care Only
Modifier -55: Postoperative Care Only
Modifier -56: Preoperative Care Only

Some procedures require the expertise of not just the primary surgeon, but also an assistant surgeon or even a surgical team. There are special rules that govern the coding and billing of a primary surgeon, assistant surgeon and surgical team. We will not go into detail about this here but be sure to review the codebook for specifics related to billing for these types of special circumstances including modifiers 62, 66, 78, 80, 81, and 82.

Generally, there will be a designated physician responsible for the postoperative care of the patient.

Calculation of the payment split among multiple providers is straightforward. The sum of the allowed amount for all the physicians will not exceed the total allowed amount, which would have been paid to a single physician who had performed all preoperative, intra-operative, and postoperative services.

What Is Included in the Global Surgical Package?

Services rendered during this period may include, but not be limited to the following:

• One preoperative visit, unless the decision to perform major surgery was made during the visit on the day of the surgery. If the decision to perform surgery was made the same day as the surgery was performed then append modifier -57 to the appropriate level of EM service for proper reimbursement.
• Intra-operative care including the performance of the surgery.
• Postoperative Care: All standard postoperative care of the patient including but not limited to removal of sutures, staples, casts, drains, tubes, packs, etc. Any wound care or dressing changes. Any care required of the surgeon due to postoperative complications or problems that do not require the patient to be taken back to the operating room for further procedures.
• Supplies used to treat any postoperative surgical complications or treatments, unless otherwise stated as exclusive.
• If the patient must be returned to the operating room for surgery for a procedure that is staged then this must be reported with modifier -58. If the procedure is unrelated, then modifier -79 would be reported. If there is an unplanned return to the operating room for a related procedure (by the performing physician) then -78 would be appended.
• Post-operative pain management.
• Office visits related to the recovery from the surgical procedure.
• Office visits related to complications that arose from the surgical procedure.

Does The Location for Treatment Change the Global Period Rules?

Care of a patient during the global surgical period is not restricted to any specific location. A patient may be treated by the surgeon (or other provider of the same medical group and specialty) in just about any location including: inpatient hospital, outpatient hospital, ambulatory surgical nursing home, surgeon’s office, emergency room, urgent care, and even the intensive care unit of a hospital.

Location will not change the fact that any care provided to the patient during the global period that is related to the procedure performed is still considered part of the global surgical package and should not be billed for separately.

How Do I Report a Postoperative Visit?

When a patient is seen and services rendered are related to the recovery and/or treatment of complications from the surgery, code 99024 should be reported to indicate this was a service related to the surgery.

What Is NOT Included in the Global Surgical Package?

Services rendered during the global period that are not related to the surgical procedure may include the following:

• The initial consultation or the EM service in which the decision for surgery is made is payable with modifier -57 appended to the EM service. Modifier -57 is only applicable to major procedures and is not applicable to the minor, 10-day global period procedures.
• Return trips to the operating room for complications from the surgery. If a return trip to the operating room is required then the global surgical period starts over again with the second surgery.
• If a second, more costly procedure is required due to failure of the less expensive procedure, both are billable and payable (see modifier section below for details).
• Office visits in which attention to diagnoses or medical conditions that are unrelated to the surgical are given are payable (see modifier section below for details).
• Diagnostic procedures such as x-rays, ultrasound or other imaging services, laboratory, or durable medical equipment.
• Medication management for conditions/diagnoses unrelated to the surgical procedure.

How Do I Bill For Unrelated Services Rendered During the Global Period?

When services are performed during the global period that are not related to the surgical procedure or complications and recovery from it, specific modifiers should be appended to the procedure code to indicate that the service provided should be paid and is unrelated to the surgery for which the patient is currently in the global period.

Modifier -24:  Indicates that the EM service, provided during the global period, was unrelated to the surgery and should be paid.

Example:  The patient was seen during the postoperative period of radiofrequency ablation of L4-5, L5-S1, which carries a 10-day global period for a new shoulder injury in which the provider evaluated the injury and ordered a MRI of the right shoulder to rule out rotator cuff tear.

In this scenario, the patient was seen for something completely unrelated to the RF ablation of L4-5, L5-S1 and therefore the appropriate level of EM would be selected based on documentation guidelines and modifier -24 would be appended to the EM code.

Modifier -25:  Indicates that the EM service provided on the same day as a surgical procedure was significant and separately identifiable as unrelated to the surgery performed.

Example:  The patient was seen in evaluation for a scalp condition, for which the provider diagnosed and prescribed medication. During the same visit, however, the patient asked the provider about a suspicious-looking mole on her right shoulder. The provider decided that it would be best to biopsy the mole to determine if it was cancerous and performed the simple biopsy during the same visit.

In this scenario, as the office visit covered care for another condition as well as determining the need to biopsy the suspicious mole, modifier -25 would be appended to appropriate level of EM to indicate it was a significant, separately identifiable service from the procedure performed that same day. Both would be payable services with the appropriate diagnoses and modifier appended to the EM service code.

A lot can happen to a patient in a 90-day period. And as a matter of fact, quite a bit can also happen during a 10-day period.

When a patient is seen during the postoperative period and undergoes another surgical procedure (minor major) by the same provider or another provider within the medical group and same specialty, a modifier must be appended to the code for the procedure performed in order for it to be paid. If no modifier is appended, the insurance company will assume it is related to the original surgery for which the patient is currently in the global period and the payment will be denied.

Modifier -78:  Unplanned return to the operating room during the postoperative period.

Example:  During a postoperative visit following appendectomy, it was discovered that the patient’s gallbladder had been accidentally lacerated. The patient was taken back to the operating room for repair of the gallbladder.

In this scenario, the return to the operating room for the gallbladder procedure would be a covered procedure related to the original surgery and therefore payable with modifier -78 appended to the gallbladder surgery code.

Modifier -79:  Unrelated procedure, performed by the same physician during the postoperative period.

Example:  The patient underwent nasoseptoplasty, which carries a 90-day postoperative period but returns during the postoperative period for repair of a lacerated lip at the vermillion border.

In this scenario, the provider performs the repair of the lacerated vermillion border and submits the insurance claim with modifier -79 appended to the procedure code and an appropriate diagnosis of lacerated vermillion border, etc. These two procedures are completely unrelated and therefore modifier -79 is the appropriate choice.

Although proper modifiers are reported, many insurance companies may require additional information to support the codes billed. Generally, a copy of the medical report for the service rendered during the global period will be requested and will suffice once reviewed by the insurance carrier.

Once reviewed the claim can then be released for payment or denied if found to be associated with the surgical procedure from which the patient is recovering.

As you can see, it is important to understand the basics of the global surgical package so that you can:

1. Maximize your billing and collection process for all surgical procedures performed
2. Receive reimbursement for services performed during the global period that are unrelated to the procedure performed through proper modifier usage.
3. Receive proper reimbursement for split global surgical procedure packages through proper modifier usage and communication between providers.

Centers for Medicare and Medicaid Services website
AMA Current Procedural Terminology by the American Medical Association

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Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding.

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