Global Periods: Let’s Make the Lingo Universal
When you can speak the language, correct reimbursement comes naturally.
As healthcare business professionals, we’re expected to know the meaning of an infinite number of terms. It’s inevitable for some terms to be misinterpreted. For example, the terms “global service,” “global surgical package,” and “global period” often are used interchangeably, but they are distinct. To create a united front, let’s look at the definition of each and discuss the differences.
Global service: The entire service represented by a specific CPT®/HCPCS Level II code, which may be divided into professional and technical components.
Global surgical package (or global surgery): The pre-operative, intra-operative, and post-operative services included in a specific CPT®/HCPCS Level II code.
Global period: The number of days included in the payment for a global surgical package.
The term global service describes all components of a service or procedure represented by a specific CPT® or HCPCS Level II code. The global service can be reported, or the services can be divided into two components: the professional portion (represented by modifier 26 Professional component) and the technical portion (represented by modifier TC Technical component). Not all CPT®/HCPCS Level II code can be divided into these two components. Per the Medicare RBRVS 2016: The Physicians’ Guide (page 108), this concept applies specifically to three types of services:
- Diagnostic tests that involve a physician’s interpretation
- Physician diagnostic and therapeutic radiology services
- Physician pathology services
For these services, the code and modifier combination used on the claim form should represent the services provided by the reporting/billing entity (e.g., the provider, the facility). Per the Medicare resource-based relative value scale (RBRVS), “The professional component includes the physician work and associated overhead and professional liability insurance (PLI) costs involved … The technical component of a service includes the cost of equipment, supplies, technician salaries, PLI, etc. The global [service] refers to both components when billed together.”
Example: A 15-year-old female patient presents to urgent care with pain in her left forearm and wrist. The physician orders a two-view X-ray of the forearm and a two-view X-ray of the wrist to be performed on site at the urgent care facility. The technician performs the ordered X-rays and the resulting films are sent to an off-site radiologist to be read (based on the urgent care facility’s contract with ABC Radiology). The radiologist reviews the images, creates the final report of findings, and sends the report to the urgent care facility.
Based on this scenario, the urgent care facility provided the technical component (equipment, supplies, technician salary, etc.) associated with the X-rays, while ABC Radiology provided the professional component (physician work – interpretation in this case). Although CPT® 73090 Radiologic examination; forearm, 2 views and 73110 Radiologic examination, wrist; complete, minimum of 3 views are appropriate for both the urgent care and ABC Radiology to report, neither should report the global service. Instead, the urgent care facility reports both codes with modifier TC appended to each, and ABC Radiology reports both codes with modifier 26 appended to each. The modifiers indicate to the insurance plan that the components of the global service were provided by two different entities and payment should be divided appropriately.
Global Surgical Package
According to CPT® 2017 Professional, in the Surgical Guidelines, under CPT Surgical Package Definition, each CPT®/HCPCS Level II code represents specific services, which include “the following surgery services when furnished by the physician or other qualified health care professional who performs the surgery:
- Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)
- Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
- Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified healthcare professionals
- Writing orders
- Evaluating the patient in the post-anesthesia recovery area
- Typical postoperative follow-up care”
Although the above services are always bundled into, or included in, each provided surgical service, depending on the payer, there may be additional services included. Many carriers, including Medicare, follow National Correct Coding Initiative (NCCI) edits. The NCCI Policy Manual for Medicare Services further details services included in more complex procedures.
Example: Chapter 1: General Correct Coding Policies, Section A: Introduction states, “A physician should not unbundle services that are integral to a more comprehensive procedure ….” Section C: Medical/Surgical Package further defines services included in a variety of different procedure classifications. Specifically, for invasive procedures requiring vascular and/or airway access, the manual states:
The work associated with obtaining the required access is included in the pre-procedure or intra-procedure work. The work associated with returning a patient to the appropriate post-procedure state is included in the post-procedure work. Airway access is necessary for general anesthesia and is not separately reportable…Visualization of the airway is a component part of endotracheal intubation, and CPT codes describing procedures to visualize the airway (e.g., nasal endoscopy, laryngoscopy, bronchoscopy) should not be reported with an endotracheal intubation …
This is just one example of the procedures/services included in specific types of global surgical procedures, according to the NCCI Policy Manual for Medicare Services.
The global period accompanies the global surgical package and further defines the services included in it — specifically, during the post-operative period. The global period further classifies surgical procedures into two categories: major and minor.
Major surgical procedures are those with a 90-day global period. The 90-day global period is a bit of a misnomer, as the number of days included in the surgical package payment for these services is actually 92. For major surgical procedures, the surgical package begins the day before surgery, includes the day of surgery, and extends 90 days after surgery.
Minor surgical procedures are those with either a zero-day or 10-day global period. Each of these global periods refers to the number of post-operative days included; neither include any pre-operative days. For minor surgeries with a zero-day global period, only the services provided (including any E/M service other than the decision for surgery) on the day of surgery are included in the package payment. For minor surgeries with a 10-day global period, the global period is actually 11 days because the package includes the day of surgery and extends 10-days post-operatively.
Many encoder systems and health plans, particularly Medicare plans, offer a global period calculator providers and coders can use to calculate easily when a global period will end. Here are just two examples:
The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-up Tool may be used to look up the global period/global days associated with each CPT®/HCPCS Level II code. Some global periods may vary from carrier to carrier. It is important to understand the global period descriptors that may appear next to a given CPT®/HCPCS Level II code.
000 = Zero-day post-operative period (endoscopies and some minor surgical procedures)
010 = Ten-day post-operative period (other minor procedures)
090 = Ninety-day post-operative period (major surgical procedures)
XXX = The global concept does not apply to the code
The procedure/service is not considered surgical.
YYY = The global period is set by the carrier
The global period may vary based on carrier.
ZZZ = Code is related to another service and always included in the global period of another service
The procedure/service is usually an add-on code and is always bundled into the primary service
MMM = A service that is furnished in uncomplicated maternity cases, including antepartum care, delivery, and postpartum care. The usual global surgical concept does not apply.
The procedure/service is pregnancy related and the obstetrical package guidelines apply, rather than the global surgical package guidelines.
Use Appropriate Modifiers
Depending on the type of surgery performed and the associated global period, any modifiers may be needed to further describe the specific circumstances of the encounter and/or accurately divide, reduce, or increase the associated payment, etc. For more information on modifier use as it relates to global surgical package payment, see the CMS Medicare Learning Network (MLN) Global Surgery Fact Sheet.
Medicare RBRVS: The Physicians’ Guide 2016, Chapter 11 Standardizing Medicare Part B: RBRVS Payment Rules and Policies, page 10
2017 CPT® Professional Edition, Surgical Guidelines, “CPT Surgical Package Definition,” page 66