Global Surgical Package: When to Bill and When Not to Bill, that is the Question

The global surgical package is inclusive of the services that would normally be provided to the patient following surgery. Depending on the global period assigned to a CPT code, the pre-operative, intra-operative and post-operative services could be included in the global surgical package.

The global period is defined by the number of global days assigned to a CPT code.

Zero day global period has no pre-operative or post-operative services included.

10-day global period has no pre-operative period, but does include a post-operative period. The global period includes 11 days - the day of the procedure and the 10 days following the procedure.

90-day global period includes a pre-operative and post-operative period. The global period includes 92 days - the day before the procedure, the day of the procedure and the 90 days following the procedure.

The global periods apply regardless of patient setting: impatient hospital (even critical care unit), outpatient hospital, ambulatory surgical center, and physician offices.

Services included in the global surgical package:

• Pre-operative visits: After the decision for surgery was made
• For 90 day global periods this would include the pre-operative visits done the day before or the day of the surgery when the decision for surgery was already made at a previous visit
• For 0-10 day global periods this would include the day of the surgery
• Intra-operative: This includes the services done as a part of the surgical procedure
• Remember when coding surgical cases it is important to review the CCI Edits to ensure that you are not unbundling and billing for services that are inclusive to the main surgery
• Post-operative visits follow up visits related to the recovery from surgery, which includes:
• post-operative pain management
• supplies (unless stated as an exclusion)
• local wound care with dressing change
• removal of operative pack, removal of sutures, staples, lines, wires, tubes, drains, casts, and splints
• insertion, irrigation and removal of urinary catheters
• removal of routine peripheral intravenous lines, nasogastric tubes and rectal tubes
• changes and removal of tracheostomy tubes

**Since the 10 day global period does not include a post-operative period, the follow up visits beyond the day of the procedure are separately billable.

Services not included in the global surgical package that are separately billable and payable:

• Initial consult: This initial evaluation of the problem and decision for the surgery is made the visit is separately billable
• 90 day global periods include the day prior to surgery
• If the evaluation and decision for surgery occur the day prior to the major procedure a -57 modifier must be appended to the E/M code, which identifies it is a separate payable service from the global period
• 0-10 day global periods have no pre- operative period, but they typically do not include separate payment for an E/M the same day as the procedure
• If there is a significant, separately identifiable service an E/M is billable on the same day as a minor procedure
• A -25 modifier will need to be appended to the E/M code
• Services of other physicians related to surgery: If a physician other than the surgeon sees the patient for a condition related to the surgery they can bill separately without a modifier
• If a physician or provider from the same group as the surgeon see the patient the service would be inclusive to the global surgery package as that practice is already being reimbursed for the entire global surgical package
• It is common for a mid-level provider from the same group as the surgeon to see patients post-operatively, this service is included

• Transfer of care: When the surgeon does not perform any portion of the post-operative care an agreement to transfer of care can be made
• This agreement would be made with a physician outside of the same group practice
• The surgeon and the physician taking over the provision of the post-operative period would need to have a written transfer agreement that needs to be present in the patients record
• The surgeon would bill the CPT codes for surgery and append modifier -54 indicating they provided surgical care only
• The physician providing post-operative care would bill the same surgical CPT codes and append modifier-55 indicating they are providing the post-operative care
• Once the physician agrees to take over the post- operative care and bill with the -55 modifier they are required to follow the post- operative guidelines, and cannot bill separately for each service/visit
• Visit for unrelated diagnosis: If the diagnosis is unrelated to the reason for surgery or if treatment is required for an underlying condition that is not normally related to recovery from surgery a separate E/M is billable
• If the surgeon is the one providing the care for unrelated conditions the -24 modifier must be appended to the E/M to indicate the service was for an unrelated reason
• Diagnostic tests and procedures
• Distinct surgical procedure during post-operative period: This would include services that are not re- operations or treatment for complications
• In this scenario, a new post- operative period would begin with the subsequent procedure, this includes staged procedures
• A modifier -79 would need to be appended to the procedural code to indicate it was an unrelated procedure
• A modifier -58 would need to be appended to the procedural code to indicate that this was a staged or related procedure
• Post-operative complications: Treatment that requires a return to the operating room
• This does not include minor treatment that can be provided in bedside or in the physician office setting
• A -78 modifier would need to be appended to the major procedure code to indicate this was an unplanned return to the operating room
• More extensive procedure required: If a less extensive procedure was tried initially and failed the more extensive procedure is separately payable
• Immunosuppressive therapy for organ transplants

• Critical care services: The patient must be critically ill and require constant attendance of the physician
• The critical care is above and beyond and usually unrelated to the anatomic injury or general surgical procedure
• The patient recovering in a critical care unit does not automatically support critical care or a service that is separately billable from the global surgical package

The Medicare Administrative Contractor Palmetto has a great resource on their website (listed below in the references area below) that allows you to type in the CPT code and it will state the global days as 0, 10 or 90. On the same page, there is a section where you can enter the date of service and it will calculate the calendar date that is 10 or 90 days past your date of service.

Remember when determining to bill and when not to bill within a global surgical package, it is important to know all of the providers involved in the patient's care. Is the provider you are billing for the surgeon? What care are they providing? What group or practice do they belong to?

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