CurrentAmbetter NevadaPolicy CC.PP.041

Pre-operative Visits / E/M Services Within Global Surgical Periods

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Defines payment rules for Evaluation & Management (E/M) visits billed on or near the day of surgical procedures (minor, major, maternity, ZZZ/add-on) and how they are handled within global surgical reimbursement packages for Ambetter Nevada.

Policy Summary

PayerAmbetter Nevada

PolicyPre-operative Visits / E/M Services Within Global Surgical Periods

Policy CodePolicy CC.PP.041

Change TypeNo material change

Effective Date01/01/2014

Last ReviewOct 16, 2025

Next Review DateOct 16, 2025

Key ActionAppend modifier 25 or 57 with supporting documentation to justify separate reimbursement for same-day or decision-for-surgery E/M visits before prepay denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

000,010,090,MMM,ZZZ

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CurrentAmbetter NevadaPolicy CC.PP.041

Pre-operative Visits / E/M Services Within Global Surgical Periods

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Policy Summary

PayerAmbetter Nevada

PolicyPre-operative Visits / E/M Services Within Global Surgical Periods

Policy CodePolicy CC.PP.041

Change TypeNo material change

Effective Date01/01/2014

Last ReviewOct 16, 2025

Next Review DateOct 16, 2025

Key ActionAppend modifier 25 or 57 with supporting documentation to justify separate reimbursement for same-day or decision-for-surgery E/M visits before prepay denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

000,010,090,MMM,ZZZ

Global period indicators

prepay editClaims editing

25,57,54,55Modifiers reviewed

Coverage Criteria for E/M Services During Global Surgical Periods

COVERAGE CRITERIA — E/M services billed within a procedure's global surgical period

E/M services billed within a procedure's global surgical period are generally considered included in the global surgical reimbursement package and are not separately reimbursed except where specific exceptions or modifiers apply.

ALL of the following

E/M services performed on the same day as a surgical procedure are included in the global surgical reimbursement package for the surgery and are not separately reimbursable unless a specific exception or modifier applies.
The global surgical reimbursement package includes pre-operative visits after the decision for surgery (for major procedures this includes the day prior and day of surgery; for minor procedures and endoscopies this includes visits on the day of surgery), post-operative visits related to recovery, intra-operative services that are part of the procedure, additional medical/surgical services requiring the surgeon's attention during the post-operative period (including complications of surgery, excluding return trips to the operating room), post-surgical pain management by the surgeon, supplies, and routine wound/dressing care.
Global surgical periods are defined by the post-operative days assigned to the procedure (000, 010, 090, MMM, ZZZ) and determine the span during which E/M services are considered included in the surgical payment.
For procedures with a 000-day global period (minor surgeries and endoscopies), only visits on the same day as surgery are included; visits the day prior are not included. For 010-day global periods, same-day visits and visits during the 10 days following surgery are included. For 090-day global periods (major surgeries), the day prior, the day of surgery and the 90 days following are included. For MMM (maternity) global periods, antepartum, same-day delivery visits, and the 45-day postpartum period are included as applicable.
E/M services that are separate and distinct from the reason for the surgery may be eligible for separate payment when appropriately documented and billed with Modifier 25 (significant, separately identifiable E/M service on the same day as a procedure).
The Decision for Surgery modifier (57) may be used to identify E/M services resulting in the decision to perform major surgery when billed on the day prior to or the day of surgery; Modifier 57 is only appropriate for major procedures when the visit results in the decision for surgery.
Modifiers 54 (surgical care only) and 55 (postoperative management only) should be used to identify each physician's participation when services are transferred between providers. Modifier 26 (professional component) may be appropriate for some procedures or ZZZ add-on codes where only the professional component is billed.
Claims editing reviews procedure codes, diagnosis codes, and modifiers to determine whether an E/M was billed within the pre-operative period of a procedure with a global period; Modifiers 25, 57, 54 and 55 are considered prior to a denial determination. The plan reviews same-claim and prior claims history and claims across dates of service and by the same provider when making determinations.
Operational note: When an E/M is billed within a surgical global period, ensure documentation clearly supports Modifier 25 or Modifier 57 use when claimed; lack of adequate documentation increases risk of denial.

Pre-operative visit coverage guidance

Pre-operative visit coverage guidance — general applicability and how pre-operative evaluations relate to global periods.

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Coding and Global Period Definitions

Modifiers affecting reimbursement for E/M services within global periodsModifier

Modifier 25	Significant, separately identifiable E/M on same day as procedure; subject to validation and requires documentation to be reimbursed.
Modifier 57	Decision for surgery on day before or day of major surgery; subject to validation and requires documentation to be reimbursed.
Modifier 54	Surgical care only - used when transferring portion of care to another physician; considered prior to denial.
Modifier 55	Postoperative management only - used when transferring portion of care to another physician; considered prior to denial.

No codes specified in this sectionmixed

No codes listed

Global period rules

000 (Zero-day)Applies only to services on the same day as the minor surgery or endoscopy; no pre-operative day included; same-day E/M is included in the surgical package unless it is significant and separately identifiable with modifier 25 and supporting documentation.

010 (10-day)Includes the day of surgery and the 10 days following the procedure (total global period 11 days); no pre-operative day included; same-day and 10-day post-op E/M services are included unless a same-day visit is significant/separately identifiable with modifier 25 and documentation.

090 (90-day)Includes the day before surgery, the day of surgery, and 90 days after (total global period 92 days); E/M on the day before or day of major surgery is included unless it results in the decision for surgery and is documented with modifier 57.

MMM (Maternity)Antepartum period of 270 days plus same-day delivery and a 45-day postpartum period are included in the maternity global package; E/M visits during antepartum, delivery day, or 45-day postpartum are not separately reimbursable when included in the maternity package.

ZZZ (Add-on/Addon)

Provider Actions, Documentation, and Appeals

Documentation Required

Prepayment Clinical Validation and Modifier Review

The Health Plan performs prepayment clinical validation and modifier review on claims. Claim lines, procedure codes, diagnosis codes and modifiers are analyzed to determine whether an E/M service was billed within the pre‑operative period of a procedure with a global surgical period (000, 010, 090, MMM, or ZZZ days). E/M services billed within a procedure's pre‑operative period are considered included in the surgical payment and are denied unless valid modifier documentation supports separate reimbursement. The Health Plan's prepayment edits review claim lines on the same claim and across a patient's claim history and multiple dates of service, and review claims billed by the same provider. Modifiers 25, 57, 54 and 55 are evaluated prior to a denial determination; Modifiers 25 and 57 require supporting documentation as described below.

Modifier 25: Claim lines with modifier 25 are subject to prepayment clinical validation. Use of modifier 25 indicates a significant, separately identifiable E/M on the same day as a procedure; documentation must substantiate the E/M beyond routine pre/post‑operative care. If documentation supports the separately identifiable E/M, the service is reimbursed; otherwise it is denied. Assign all applicable diagnosis codes that indicate need for the additional E/M service.
Modifier 57: Claim lines with modifier 57 are subject to prepayment clinical validation. Review includes E/M and surgical DOS, diagnosis and procedure codes and other claim details to determine if the initial decision to perform surgery occurred on the day before or day of a major surgery. If documentation supports the initial decision to perform surgery, the E/M is reimbursed; otherwise it is denied.

Definitions and Key Terms

Global surgical reimbursement package

DefinitionA global surgical reimbursement package bundles the surgical procedure payment with related services including E/M services, anesthesia, immediate postoperative care, written orders, evaluation in the post-anesthesia recovery area, and typical postoperative follow-up care provided before, during and after a procedure.

Included servicesNecessary services performed before, during or after a surgical procedure are considered components of the surgical procedure and are subsumed into the surgical reimbursement.

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

Global surgical period types

000 - Zero DayGlobal period applies only to services on the same day as minor surgery or endoscopy; no pre-operative day; same-day E/M included unless significant/separately identifiable (modifier 25).

Policy Summary

PayerAmbetter Nevada

PolicyPre-operative Visits / E/M Services Within Global Surgical Periods

Policy CodePolicy CC.PP.041

Change TypeNo material change

Effective Date01/01/2014

Last ReviewOct 16, 2025

Next Review DateOct 16, 2025

Key ActionAppend modifier 25 or 57 with supporting documentation to justify separate reimbursement for same-day or decision-for-surgery E/M visits before prepay denial.

SourceLink

On This Page

Add-on procedure codes billed with a primary service follow the primary procedure's global period; when the primary procedure includes an inherent E/M component, separate reimbursement for E/M is not allowed.

Precedence

State Medicaid precedenceWhen state Medicaid coverage provisions conflict with this payment policy, the state Medicaid provisions take precedence.

Medicare NCDs/LCDsApplicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed and take precedence where applicable.

Legal & regulatory requirementsIf discrepancies exist between this payment policy and legal or regulatory requirements, the requirements of law and regulation govern.

Modifiers 54 and 55: Considered during prepayment review prior to denial determination.

Prior Authorization

Appeals/Reconsiderations

If a provider disagrees with a prepayment denial or edit determination, the provider may submit an appeal or reconsideration request in accordance with Health Plan rules. The request must include all relevant medical records and supporting documentation to substantiate that the billed E/M or modifier usage meets the policy criteria. Providers should follow the Health Plan's established appeal/reconsideration process and timelines.

Submit complete medical records and supporting documentation with the appeal/reconsideration request.
Follow Health Plan-specific appeal/reconsideration procedures and timelines.

Note

Provider Responsibilities and Independence

This payment policy is a reimbursement guide and does not dictate clinical practice. Providers are expected to exercise professional medical judgment in treating members and remain solely responsible for medical care decisions. Providers are independent contractors; they are not agents or employees of the Health Plan. The Policy does not constitute medical advice or require specific clinical actions—providers should apply their professional judgment and follow applicable laws, regulations, and contract terms.

Policy is a payment guide — it does not replace clinical judgment or physician–patient decision making.
Providers are responsible for documentation that supports billed services and modifier use.
Where state Medicaid or Medicare NCD/LCD rules apply, those requirements take precedence over this payment policy.

010 - 10-DayCovers the day of surgery plus 10 post-operative days (total 11 days); same-day and 10-day post-op E/M included in the package unless same-day E/M is significant/separately identifiable (modifier 25).

090 - 90-DayCovers the day before surgery, the day of surgery, and 90 post-operative days (total 92 days); day-before or same-day E/M may be reimbursed when visit results in decision for surgery with modifier 57 documented.

MMM - MaternityIncludes a 270-day antepartum period, same-day delivery, and a 45-day postpartum period; E/M visits during these intervals are included in the maternity global package and not separately reimbursable when included.

ZZZ - Add-onAdd-on surgical procedure codes must be billed with a primary service and follow the primary procedure's global period; separate reimbursement for E/M is not allowed if the primary procedure includes an inherent E/M code.

Modifier 25

DefinitionModifier 25 indicates a significant, separately identifiable E/M service on the same day as a procedure beyond the typical pre-/post-operative care.

Documentation requirementClaim lines with modifier 25 are subject to prepayment clinical claims validation and must be substantiated by documentation that satisfies the relevant E/M criteria; if documentation supports the separate E/M, the service is reimbursed; otherwise it is denied.

Coding guidanceTo avoid incorrect denials, assign all applicable diagnosis codes that indicate the need for the additional E/M service when appending modifier 25.

Modifier 57

DefinitionModifier 57 indicates that the E/M visit resulted in the initial decision to perform major surgery on the day before or the day of the surgery.

Documentation requirementClaim lines with modifier 57 are subject to prepayment clinical claims validation; documentation must demonstrate that the decision for surgery occurred on the day before or the day of the major surgery for the E/M to be reimbursed.

Validation factorsPrepayment review analyzes E/M and surgical dates of service, diagnosis codes, procedure codes billed, and other claim information to determine if modifier 57 is supported.

'Health Plan' definition

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 of its affiliates, as applicable.

Policy roleThis payment policy is a guide to payment and does not constitute a contract, guarantee of payment, or medical advice; coverage and payment are subject to plan documents and legal/regulatory requirements.

Provider relationshipProviders are independent contractors, not agents or employees of the Health Plan, and are expected to exercise professional medical judgment in care decisions.