Your Quick Guide to the Global Surgical Package
Make quick and easy work of determining which procedures and services are bundled and when.
Most coders, billers, and clinicians are familiar with the concept of the surgical package or global period; but they may be unclear about when the global period begins and ends, and which procedures and services may be reported (and paid for) separately during that time. Use this guide to code with confidence.
Define the Surgical Package
Imagine you’re vacationing at an all-inclusive resort. Your room, food, entertainment, and transportation within the resort are included for a single price. This “one price” concept also applies to the surgical package. As defined by the Centers for Medicare & Medicaid Services (CMS):
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 pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty.
Exactly which procedures and services are included in the surgical package depends on the payer. Per Surgery Guidelines, CPT® Surgical Package Definition:
… the following services related to the surgery when furnished by the physician or other qualified health care professional who performs the surgery are included in addition to the operation per se:
- 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 health care professionals
- Writing orders
- Evaluating the patient in the postanesthesia recovery area
- Typical postoperative follow-up care
The list of procedures and services included in the global package is similar in CMS’ MLN Booklet, Global Surgery Booklet. Medicare includes the following services in the global surgery payment when provided in addition to the surgery:
- Pre-operative visits after the decision is made to operate. For major procedures, this includes pre- operative visits the day before the day of surgery. For minor procedures, this includes pre-operative 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 post-operative period of the surgery because of complications, which do not require additional trips to the operating room
- Follow-up visits during the post-operative 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
- 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’s Not Included?
Medical procedures or services unrelated to the global package procedure aren’t included in the global package and may be reported (and reimbursed) separately.
Per CMS, 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.
- 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 post-operative period which are not re-operations or treatment for complications
- 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
- 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
Not All Global Packages Are Equal
Just as important as knowing what is (and is not) included in the global package is knowing when the global package begins and ends. When a global package begins and ends depends on the type of procedure or service reported.
Minor procedures are relatively simple and may have either a 0-day or 10-day global period. A 0-day global means there is no pre-operative period and no post-operative days. That is, the global package applies for one day, only (the day of the procedure or service).
A 10-day global has no pre-operative period and a 10-day post-operative period. This means the global package applies for 11 days (the day of the procedure or service, and 10 days following).
Major procedures are more resource-intensive, require a longer recovery for the patient, and have a 90-day global period. The global package for a major procedure begins one day before the procedure or service and includes the day of service plus the 90 days that follow (a total of 92 days).
You can find global periods for all CPT® codes using AAPC Coder or other encoder software, or in the CMS Physician Fee Schedule Relative Value File. In addition to “000,” “010,” and “090” day global periods, you may also see indicators “XXX” (global period does not apply), “ZZZ” (add-on code), “YYY” (global period determined by payer), and “MMM” (maternity).
Reporting E/M Services During the Global Period
There are two circumstances when you may report an E/M service separately during a global period.
- You may separately report the E/M service that led to the decision to perform the global package procedure.
When an E/M service leads to the decision to perform a minor procedure (0- or 10-day global period) on the same date of service, you should append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service to the appropriate E/M service code.
When reporting a separate E/M service with modifier 25 appended, the documentation should describe an independent, standalone E/M service in addition to the procedure. In other words, if you were to delete from the visit note all documentation referencing the procedure, the remaining documentation should support a medically-necessary, separate E/M visit, including a chief complaint, a relevant history and exam, and medical decision-making with an assessment and treatment plan.
For example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E/M service is not separately reported. If the physician also performs a medically reasonable and necessary full neurological examination, however, an E/M service may be separately reported.
The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 1 – General Correct Coding Policies, also states that it does not matter if the patient is new or established — a new patient receiving a procedure does not automatically qualify for modifier 25.
When an E/M service leads to the decision to perform a major procedure (90-day global period) on either the same date of service or the day before that procedure, append modifier 57 Decision for surgery to the appropriate E/M service code. Remember: The global period for major procedures begins one day prior to the actual procedure.
CPT® Assistant (March 2015) provides an example:
A patient is seen in the emergency room with acute appendicitis. The surgeon sees the patient, makes a diagnosis, and reaches a decision to perform surgery. The patient then promptly undergoes a laparoscopic appendectomy.
How to Code
Report CPT® code 992[XX] (or similar initial emergency department code) with modifier 57, along with the appropriate appendectomy code: 992[XX]-57 and 44970.
- You may separately report an E/M service during a global period if the E/M service is unrelated to the global package procedure or service.
Various payers define “unrelated” differently in this context. According to CMS, an E/M service provided during the global period of a procedure is unrelated if:
- The E/M service is for treatment of a problem unrelated to the surgery
- The E/M service is for treatment of the underlying condition that prompted the procedure
CMS considers E/M services for pain control and wound care to be related post-operative care, as is any complication that doesn’t require a return to the operating room.
The CPT® code book also defines an unrelated E/M service as occurring for treatment of a problem unrelated to the surgery or for treatment of the underlying condition that prompted the procedure; but unlike CMS, CPT® allows that a separately-billable E/M service may be appropriate for wound care, pain management, or treatment of complications of surgery.
Example 1: A patient presents for 30-day follow-up after hip replacement. At that visit, the patient complains of new onset of shoulder pain. The provider documents the elements of an E/M service to evaluate and treat the shoulder pain. Under both CPT® and CMS guidelines, this E/M service is unrelated to the previous procedure because the shoulder pain is not connected to the hip replacement.
Example 2: A patient presents for 30-day follow-up after hip replacement and complains of pain, swelling, and discharge at the site of the hip replacement. The provider documents the elements of an E/M service to evaluate and treat this complication. Under CPT® rules, the E/M service is unrelated to the hip replacement. Under CMS rules, the E/M service is related to the hip replacement because it is a complication of the previous procedure and is not separately reimbursed.
Example 3: A patient undergoes breast biopsy (e.g., 19101 Biopsy of breast: open incisional). The results reveal malignancy, and the patient returns within the 10-day global period to discuss treatment options. The provider documents the required elements of an E/M service. Under both CMS and CPT® guidelines, this E/M is unrelated to the previous biopsy because it is for treatment of the underlying condition that prompted the biopsy.
Medicare and Medicaid payers follow CMS guidelines. Other payers may follow CMS, CPT®, or specify their own guidelines.
Reporting non-E/M Services During the Global Period
Non-E/M services reported during a global period must meet the requirements to apply one of three possible modifiers.
- Modifier 58
Append modifier 58 Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period to indicate that the present procedure meets one (or more) of the following three conditions:
- The follow-up procedure was planned prospectively, or at the time of the initial procedure. CPT® Assistant (February 2008) clarifies, “Decisions to perform subsequent procedure(s) may depend on the outcome of the surgery and the patient’s postoperative status.” Do not append modifier 58 if the code descriptor specifies “one or more visits” or “one or more sessions” (e.g., 66762 Iridoplasty by photocoagulation (1 or more sessions) (eg, for improvement of vision, for widening of anterior chamber angle)).
- The follow-up procedure is more extensive than the initial procedure. The follow-up procedure must be performed to treat the patient’s underlying condition, rather than due to a complication of the initial procedure.
- For therapy following a diagnostic surgical procedure. For example, the NCCI Policy Manual for Medicare Services, Chapter 1 – General Correct Coding Policies, explains:
- If a diagnostic endoscopy is the basis for and precedes an open procedure, the diagnostic endoscopy is separately reported with modifier 58. However, the medical record must document the medical reasonableness and necessity for the diagnostic endoscopy.
In this case, the open procedure is a therapeutic procedure following a diagnostic endoscopy.
There’s no requirement for the patient to return to the operating room to use modifier 58.
- Modifier 78
If a provider returns a patient to the operating room to treat complications during the global period, report the treatment separately by appending modifier 78 Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period to the appropriate CPT® code. This is true regardless of payer.
For example, if the provider must return the patient to the operating room during the global period to excise infected tissue at the incision site of a hip replacement, report the appropriate debridement code (e.g., 11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface) with modifier 78 appended.
- Modifier 79
CPT® modifier 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period applies when the same provider (or a provider of the same specialty within a group of physicians billing under the same tax identification number) performs an unrelated surgical procedure during the postoperative period of another procedure.
To illustrate proper use, CPT® Assistant (September 2010) provides an example:
A 68-year-old woman had an unfortunate landing while bicycling and sustained a mildly non-displaced closed fracture of the right distal ulna. Because of the patient’s condition and the nature of the injury, closed manipulation treatment was performed in the operating emergency room, with placement of a long-arm plaster splint. The patient was discharged. Later in the day, the patient returned to the emergency department after experiencing nasal bleeding with clots. After unsuccessful pressure packing insertion and the use of local vasoconstrictors, the patient was returned to the operating room, where bleeding was controlled by repair of a posterior arterial hemorrhage with cautery.
The proper coding is 25535 Closed treatment of ulnar shaft fracture; with manipulation and 30905 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial with modifier 79 appended. As CPT® Assistant explains, “In this case, the medical documentation reflected that the postprocedural bleeding was not attributable to the initial operation.”
MLN Booklet, Global Surgery Booklet
The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 1 – General Correct Coding Policies
CPT® Assistant (March 2015)
CPT® Assistant (February 2008)
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