CurrentAmbetter NevadaPolicy CC.PP.042

Payment Policy: Post-operative Visits

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Defines when evaluation and management (E/M) services billed during a surgical global period are considered included in the surgical package and not separately reimbursable; applies to providers and facilities billing Ambetter Nevada. (Partial document — further sections may follow.)

Policy Summary

PayerAmbetter Nevada

PolicyPayment Policy: Post-operative Visits

Policy CodePolicy CC.PP.042

Change TypeNo material change

Effective DateDec 1, 2024

Last ReviewOct 14, 2025

Next Review DateOct 14, 2025

Key ActionProviders should submit appeals or reconsideration requests with supporting medical records if they disagree with prepay edit denials for E/M services billed during surgical global periods.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentAmbetter NevadaPolicy CC.PP.042

Payment Policy: Post-operative Visits

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Policy Summary

PayerAmbetter Nevada

PolicyPayment Policy: Post-operative Visits

Policy CodePolicy CC.PP.042

Change TypeNo material change

Effective DateDec 1, 2024

Last ReviewOct 14, 2025

Next Review DateOct 14, 2025

Key ActionProviders should submit appeals or reconsideration requests with supporting medical records if they disagree with prepay edit denials for E/M services billed during surgical global periods.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

000,010,090,MMM,ZZZGlobal period indicators referenced

24,25,55,57,26Modifiers discussed

Prepay editsClaims processed

Coverage Criteria for E/M Services During Surgical Global Periods

COVERAGE CRITERIA

E/M services during the global period are generally included in the surgical package and not separately reimbursed unless specific conditions or modifiers/documentation justify separate payment.

E/M services performed on the same day as a surgical procedure are included in the global surgical reimbursement package and are not separately reimbursable unless specific modifiers/documentation justify separate payment.

Global period definitions

000 (zero) day global period: applies only to visits and services that occur on the same day as minor surgeries and endoscopies; same-day E/M visits are not separately payable unless significant and separately identifiable — append modifier 25.
10-day global period: for certain minor surgeries and endoscopies; E/M services on the day of surgery and within 10 days following are included and not separately payable unless significant and separately identifiable — append modifier 25.
90-day global period: for major surgeries; includes the day before surgery, the day of surgery, and 90 days following. E/M services on the day before or the day of surgery are reimbursable when they result in the decision to perform major surgery — append modifier 57. E/M services within the 90-day post-operative period are not separately payable.
MMM (maternity) global period: includes antepartum visits (270 days), same-day delivery visits, and a 45-day postpartum period; E/M services during these periods are not recommended for separate reimbursement when included in the maternity package.
ZZZ add-on procedures: are billed with a primary procedure; the global period is based on the primary procedure and if the primary includes an inherent E/M component, separate reimbursement for the E/M is not allowed; modifier 26 may be appropriate for professional component when applicable.

Same-day visits that are separate and distinct from the reason for the procedure may be reported separately when documentation supports the service is significant and separately identifiable; append modifier 25 to the E/M code to indicate this.

E/M services that are unrelated to the surgical procedure may be separately reimbursed when supported by documentation and appropriate modifier usage (e.g., modifier 24). Claims with modifier 24 appended to the E/M are subject to prepayment clinical claims validation to determine unrelatedness; if validated, the E/M is reimbursed, otherwise denied.

Services billed with modifier 55 (postoperative management only) are subject to prepayment clinical claims validation; providers using modifier 55 should bill the surgery date as the date of service and must document appropriate billing for any separately billed visits during the postoperative period.

Claim lines containing E/M codes billed within the post-operative period of a minor, major or maternity procedure are evaluated by prepay code edits and are typically denied as included in the surgical payment unless modifiers/documentation warrant separate payment. Reviews include claim lines on the same claim, across claims, across dates of service, and by the same provider.

Providers may submit appeals or requests for reconsideration with full medical records and supporting documentation if they disagree with denial determinations following prepayment edits and clinical validation.

Coverage guidance and legal/operational notes

Guiding statements on application of the payment policy and precedence of other rules:

This payment policy is a guide to payment to assist in coverage and payment determinations and administering benefits; it does not constitute a contract or guarantee of payment or results.

Coverage and payment determinations are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents as well as applicable state and federal requirements and plan-level administrative policies and procedures.

Health Plan may change, amend or withdraw this payment policy at any time; the effective date of the policy is determined by Health Plan and may differ from the posting date.

For Medicaid members, when state Medicaid coverage provisions conflict with this payment policy, state Medicaid provisions take precedence; refer to the applicable state Medicaid manual.

For Medicare members, applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed prior to applying the criteria in this payment policy.

Coding, Modifiers, and Prepay Editing

Modifiers and coding notesModifier

Modifier 25	Used when a same-day E/M service is significant and separately identifiable from the procedure; may permit separate reimbursement for 000 or other global periods when justified.
Modifier 57	Decision for Surgery — used for E/M services that result in the decision to perform major surgery (major procedures only).
Modifier 24	Unrelated E/M during postoperative period — subject to clinical validation to determine unrelatedness.
Modifier 55	Postoperative management only — subject to clinical validation; billing provider should bill the surgery date as date of service.
Modifier 26	Professional component — may apply for some ZZZ add-on procedures.

inv-04: Prepayment edit trigger

TriggerE/M codes billed within the post-operative period of surgeries with global surgical indicators 010, 090, MMM or ZZZ are analyzed by the Health Plan's prepay code editing software and are typically denied unless a valid modifier or supporting documentation justifies separate payment.

Scope of analysisPrepay edits evaluate claim lines, procedure codes, diagnosis codes and modifiers to detect E/M services billed during the global period.

Review breadthReviews include claim lines on the same claim, across prior claims in the patient history, across multiple dates of service, and by the same provider.

Modifiers considered prior to denialModifiers 24 and 55 are specifically considered before a denial determination is made.

Typical outcomeClaim lines containing E/M codes billed within the post-operative period of minor, major or maternity procedures are denied as included in the surgical payment unless validated.

Provider Actions, Appeals, and Policy Purpose

Denial Risk

Prepay claim editing and appeals for E/Ms in global periods

Claims that contain evaluation and management (E/M) codes billed within the post-operative global period for minor, major, or maternity procedures are subject to prepay claim edits and will be denied as included in the surgical payment unless documentation or an applicable modifier justifies separate payment. Prepayment review includes analysis of claim lines on the same claim and across a patient's claim history, across multiple dates of service, and by the same provider. Providers may submit an appeal or reconsideration request with all medical records and supporting documentation if they disagree with a prepayment edit determination.

Claim lines with E/M codes billed within the post-operative period of minor, major, or maternity procedures are denied as included in the surgical package.
Modifiers 24 and 55 are reviewed prior to denial determinations; documentation supporting modifier use must be provided.
Prepay edits review same-claim lines, across claims in the patient’s history, across multiple dates of service, and claims billed by the same provider.
If a provider disagrees with a denial, submit an appeal or reconsideration request accompanied by all medical records/supporting documentation per health plan rules.

Definitions and Global Period Examples

inv-07: Global surgical reimbursement package

Included pre-operative visitsPre-operative visits after the decision for surgery are included in the global surgical reimbursement package (major procedures include day-before and day-of visits; minor procedures include day-of visits).

Intra-operative servicesIntra-operative services that are routine parts of the surgical procedure are included in the package.

Post-operative visits and complicationsPost-operative visits related to recovery and additional medical or surgical services requiring the surgeon's attention during the post-operative period, including complications (but excluding return trips to the OR), are included.

Pain management and routine carePost-surgical pain management by the surgeon, dressing changes, local incision care, removal of operative pack, sutures/staples, and routine local care are included.

SuppliesSupplies used in the surgical and immediate post-operative care are included in the surgical package.

Policy Summary

PayerAmbetter Nevada

PolicyPayment Policy: Post-operative Visits

Policy CodePolicy CC.PP.042

Change TypeNo material change

Effective DateDec 1, 2024

Last ReviewOct 14, 2025

Next Review DateOct 14, 2025

Key ActionProviders should submit appeals or reconsideration requests with supporting medical records if they disagree with prepay edit denials for E/M services billed during surgical global periods.

SourceLink

On This Page

Providers are independent contractors, not agents or employees of Health Plan, and are responsible for medical advice and treatment of members; this policy does not provide medical advice or dictate clinical practice.

The content of this payment policy is the property of Centene Corporation; unauthorized copying, use, or distribution is prohibited.

Documentation Required

Policy purpose and limitations — not a contract or guarantee

This payment policy is a guide to payment to assist in coverage and payment determinations and administering benefits; it does not constitute a contract or guarantee of payment or results. Coverage and payment determinations remain subject to the terms, conditions, exclusions, and limitations of the applicable coverage documents and to state and federal requirements and plan-level administrative policies and procedures.

The policy is effective on the date determined by the Health Plan; posting date may differ from the effective date.
State Medicaid provisions and applicable NCDs/LCDs or other legal/regulatory requirements may take precedence where applicable.

E/M services performed on the same day as a surgical procedure are included in the global package and not separately reimbursable unless a specific CPT modifier justifies separate payment.

inv-08: Global period examples

000-day example000 — Zero day post-operative period: applies to minor surgeries and endoscopies; global period applies only to services on the same day as surgery.

10-day example10-day — E/M services that occur within 10 days of surgery for procedures with a 10-day global period are not separately payable; total global period counts the day of surgery plus 10 days (11 days total).

90-day example90-day — Major surgeries: includes the day before, the day of surgery, and 90 days following (total global period 92 days); E/M on day prior or day of that result in decision for surgery may be billed with modifier 57.

MMM (maternity) exampleMMM — Maternity global: 270-day antepartum period, same day of delivery included, and 45-day postpartum period; visits during these periods are not recommended for separate reimbursement when included in the maternity package.

inv-09: Decision for Surgery

DefinitionDecision for Surgery describes E/M services that result in the decision to perform major surgery; such E/M services may be reported separately when they lead to that decision.

Modifier 57 usage constraintModifier 57 (Decision for Surgery) may only be appended to E/M services for major surgical procedures and is appropriate when the visit results in the decision to perform the surgery.

Same-day/day-before applicabilityFor major surgeries, E/M services on the day before or the day of surgery are reimbursable when those visits result in the decision to perform surgery and modifier 57 is appended.

inv-10: 'Health Plan' definition

Health Plan definition'Health Plan' means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan's affiliates, as applicable.

Policy roleThe payment policy is a guide to payment and assists in making coverage and payment determinations; it is not a contract or guarantee regarding payment or results.

ApplicabilityCoverage and payment determinations are subject to terms, conditions, exclusions and limitations of coverage documents and applicable state and federal requirements.