CurrentAnthemPolicy G-06041

Global Surgical Package

Defines Anthem Blue Cross and Blue Shield Medicaid's reimbursement rules for the global surgical package, including what services are included or reimbursable separately, and who this applies to (providers billing Medicaid managed care in Ohio).

Policy Summary

PayerAnthem

PolicyGlobal Surgical Package

Policy CodePolicy G-06041

Change TypeNo material change

Effective DateJan 30, 2023

Next Review Date

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0/10/90postoperative periods used to define major/minor procedures

Included / Separatedistinct lists of services

06/03/2025policy history entry

Ohiopayer/state scope

Global Surgical Package — What’s Included and Excluded

Global package inclusion and exclusions

Policy Summary

PayerAnthem

PolicyGlobal Surgical Package

Policy CodePolicy G-06041

Change TypeNo material change

Effective DateJan 30, 2023

Next Review Date

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

On This Page

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ALL of the following

ALL of the following
- Beginning with the day before surgery for major procedures
- Beginning with the day of surgery for minor procedures
E/M services rendered after the decision for surgery has been made
Intraoperative services that are normally a usual and necessary part of a surgical procedure, including miscellaneous surgical services and supplies (e.g., surgical kits)
Fluid and drug administration services provided intraoperatively (therapeutic drugs, prophylactic drugs, local anesthetic injections, anesthetic blocks or agents, topical anesthesia, unspecified/unclassified drug codes administered by the operating provider)
Intraoperative pain management and devices, including moderate sedation
Visits during the postoperative periods related to recovery from the surgery, regardless of place of service (includes clinic or facility fees associated with typical postoperative care)
Medical or surgical services for postoperative complications that do not require additional trips to the operating room and are not hospital-acquired conditions (HAC) or present on admission (POA)
Postsurgical pain management by the surgeon

ALL of the following

The initial consultation or evaluation by the surgeon to determine the need for a major surgical procedure
Services of other physicians, unless a transfer of care is documented in writing or in the medical record (discharge summary, hospital record, or ASC record)
Visits during the postoperative period that are unrelated to the diagnosis of the surgery, unless due to complications of the surgery
Treatment for an underlying condition or an added course of treatment that is not part of the normal recovery from surgery
Diagnostic tests and procedures
Clearly distinct surgical procedures during the postoperative period that are not re-operations or treatment for complications

ALL of the following

Unlisted surgical procedures (YYY) are reviewed individually; claims must include a written description, office notes, and the operative report for review
Global period for an add-on surgical procedure is based on the primary surgical code (add-on codes are included in the primary service global period)

Relevant Codes and Documentation Requirements

Global surgery indicator codes and notesCPT | Modifier

XXX	Codes that the global surgery concept does not apply
YYY	The health plan/MAC determines the global period. The global period for these codes will be 0, 10, or 90 days.
ZZZ	Code related to another service (add-on code) and is always included in global period of the primary service.

Unlisted procedure documentation requirementsCPT

unlisted

Unlisted surgical procedures require a written description, office notes, and an operative report for review

Documentation required for unlisted codes (YYY)

Required documentationClaims with unlisted surgical procedure codes must include a written description of the procedure, relevant office notes, and the operative report for review.

PurposeDocumentation is used to describe the unlisted procedure on an individual claim basis to determine appropriate reimbursement.

Submission requirementAll three elements (written description, office notes, operative report) must be submitted with the claim for consideration.

Authorization, Billing, and Documentation Actions

Prior Authorization

Obtain authorization, document medical necessity, and bill with supported codes

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; reimbursement applies unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. Providers must bill with proper CPT/HCPCS/revenue codes and fully support billed services in the medical record or office notes. Failure to follow coding/billing or current reimbursement policies may result in claim rejection or denial, and the plan may recover or recoup payment.

Use industry-standard, compliant codes (CPT, HCPCS, revenue codes) on all claim submissions and ensure documentation supports billed services (medical record and/or office notes).
Authorization and medical necessity must be obtained and documented per the member's benefit plan and state of residence.
Noncompliance with coding/billing guidelines or policy may lead to claim rejection/denial or recovery/recoupment of payments.

Definitions and Global Period Classifications

Global surgery (definition)

DefinitionThe global surgical package includes all necessary services normally furnished by a surgeon before, during, and after a procedure.

SynonymAlso called global surgery or the global surgical package.

ScopeEncompasses preoperative, intraoperative, and postoperative care related to the surgical procedure.

Major procedures

Global period length90-day global surgical period.

ClassificationCodes designated as major procedures carry the 90-day postoperative period.

Reimbursement implicationPostoperative services related to the major procedure are included in the global package and not separately reimbursable during the 90-day period unless exceptions apply.

Minor procedures

Global period options0-day or 10-day global surgical periods depending on procedure complexity.

ClassificationCodes designated as minor procedures will have either a 0-day or 10-day postoperative period based on complexity.

Reimbursement implicationPostoperative services related to minor procedures are included in the global package for the designated 0- or 10-day period and are not separately reimbursable during that time.

XXX (codes without global surgery applicability)

XXX definitionCodes to which the global surgery concept does not apply.

TreatmentThese codes are excluded from global package rules; standard coding and reimbursement policies apply.

IdentificationCodes labeled 'XXX' in coding tables indicate no global period applies.

YYY (codes with plan/MAC-determined global period)

YYY definitionCodes for which the health plan or MAC determines the global period; the global period for these codes will be 0, 10, or 90 days.

Review processReimbursement and applicable global period for YYY codes are determined on review of the claim and supporting documentation.

Unlisted overlapUnlisted surgical procedures classified as YYY require submission of written description, office notes, and operative report for consideration.

ZZZ (add-on codes and global period inclusion)

ZZZ definitionAdd-on codes related to another service that are always included in the global period of the primary service.

Inclusion ruleGlobal period for an add-on (ZZZ) is determined by the primary surgical code and is not paid separately outside that primary service's global period.

Coding noteZZZ codes are identified as add-on codes and should be billed in conjunction with the primary procedure code.