Rules governing which services are included in the global MAP, which may be paid separately, division of payment when multiple providers furnish components, and exclusions for adverse events.
The global maximum allowable payment (MAP) for a surgical procedure is a single fee billed and paid for all necessary services normally furnished by the surgeon before, during and after the procedure; the global period is determined by procedure category (major, minor, zero-day).
Services included in the global surgical package (not separately reimbursable): preoperative visits per global period, intraoperative services (including monitoring), local infiltration/topical anesthesia, complications not requiring additional OR trips, postoperative visits during the global period, post-surgical pain management by the surgeon, initial casting/splints/supplies, and miscellaneous routine post-op services (dressing changes, removal of sutures/staples, lines/tubes/drains care, routine peripheral IVs).Major = day before + day of + 42 days; Minor = day of + 10 days; Zero day = day of procedure only
Services that may be payable separately when appropriately reported
Initial consultation or evaluation for major surgeries may be billed separately when reported with modifier 57.
New patient office or outpatient E/M services (CPT 99202-99205) are allowable on the day of the procedure.
Visits or services unrelated to the procedure’s diagnosis may be reported separately with appropriate modifiers (e.g., modifier 24 or 25 for E/M, modifier 79 for unrelated procedure) and supporting diagnoses.
Treatment for an underlying condition or added course of treatment not part of normal recovery may be reported separately with appropriate modifiers.
Diagnostic tests and procedures, including diagnostic radiology, may be paid separately.
Clearly distinct surgical procedures during the postoperative period that are not reoperations or treatment for complications may be paid separately; use modifier 78 when a related procedure during the postoperative period ends the original postoperative period and begins a new one.
Modifier requirements and documentation: Modifiers 22, 24, 25 and 78 must be billed when applicable; failure to include required modifier may result in denial. Claims with modifier 22 require supporting documentation (operative report or medical record) explaining increased service. Modifier 52 may result in reduced allowance reflecting a lesser service.
When more than one physician furnishes services included in the global package and transfer of care occurs (except physicians in group practice), payment for out-of-hospital postoperative care may be split evenly among agreeing physicians; total payments may not exceed the single‑physician amount. Use modifiers 54 (surgery only), 55 (postoperative management only) and 56 (preoperative management only) as appropriate.
Reimbursement: BCBSKS will pay each physician directly for the portion of the global surgery services they furnished; percentages have been established for families of procedures when out-of-hospital postoperative care is furnished by someone other than the surgeon.
Adverse events and retained foreign objects
Adverse events designated by BCBSKS (including CMS 'Never Events' related to physicians) are not billable to BCBSKS; specifically, surgery on wrong body part, surgery on wrong patient, and wrong surgical procedure — no payment to the provider and patient held harmless.
Retention of foreign object: if the same provider who caused the retention removes the object, no payment will be made and the patient is held harmless; if a different provider removes the object, that provider shall receive payment.
Exceptions and special allowances: Occasional post-discharge services by a physician other than the surgeon may be reported and will be evaluated for medical necessity and payment; itinerant surgeon arrangements may affect billing and fee division. For cardiac pulmonary bypass postoperative bleeding, up to 20% of the initial surgeon fee may be allowed; other complications are considered individually.