CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP014

Global Surgical Package - Professional Providers

Defines reimbursement and coding rules for the global surgical package for professional providers (physicians and other qualified health care professionals) under BCBSNM plans, including included/excluded services, global periods, modifiers, and billing expectations.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyGlobal Surgical Package - Professional Providers

Policy CodePolicy CPCP014

Change TypeTechnical/reference — no material changes

Effective DateJan 22, 2024

Next Review Date

Key ActionSubmit supporting documentation upon request and ensure accurate claim coding with HIPAA-approved code sets.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

000,010,090Global Surgery Indicators referenced

92 daysTotal global period for major surgery

100%Max eligible reimbursement (split services)

CPCP014Policy identifier

Global Package Coverage Criteria

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Global package coverage criteria

Coverage determination for services related to surgical procedures:

ALL of the following

Pre-operative visits as defined (day before surgery for major procedures; day of surgery for minor procedures).
Evaluation and management services for minor surgery on the day of the minor surgery when included in Global Days Value 000-010.
Local infiltration, tumescent anesthesia, metacarpal/metatarsal/digital block, or topical anesthesia.
Intra-operative services usual and necessary to the surgical procedure (including administration of fluids and drugs during the procedure).
Immediate post-operative care, including dictating operative notes and communicating with family and other clinicians.
Writing orders and evaluating the member in the post-anesthesia recovery area.
Post-operative follow-up care during the designated global period related to recovery from the surgery (follow-up E/M visits related to recovery are included).
Postsurgical pain management when performed by the surgeon or same specialty/subspecialty physician or other QHP within the same group.
Supplies except those specifically identified as exclusions; miscellaneous routine services (dressing changes; suture/staple removal; catheter management; removal of drains, lines, casts, splints; tracheostomy care).
Services and supplies rendered by a provider or another physician/QHP within the same group and specialty/sub-specialty and across settings (inpatient, outpatient, ASC, office).

ALL of the following

Initial consultation or evaluation to determine the need for major surgery.
Services performed by other physicians unless there is an agreed transfer of care with documentation submitted for eligible reimbursement.
Visits unrelated to the surgical diagnosis unless performed due to complications of the surgery.
Treatment of the underlying condition or added courses of treatment not part of normal recovery.
Diagnostic tests and procedures (including diagnostic radiology) conducted to evaluate the condition.
Clearly distinct surgical procedures during the post-operative period that are not repeat operations or treatment for complications.

ALL of the following

Appropriate modifiers should be appended to CPT/HCPCS codes to indicate whether a service is part of the global period; incorrect modifier-to-procedure combinations may result in claim denial and require corrected claim submission.
Modifier 24 and/or 25 should not be appended to services rendered during the global period unless the medical record documents the visits were separate and unrelated.
Common modifiers for global period billing consideration include: 24, 25, 54, 55, 56, 57, 58, 76, 77, 78, 79 and FT (FT applies only to critical care codes and requires documentation that critical care was unrelated to the procedure).

ALL of the following

When pre- and/or post-operative services are provided by a different physician or QHP than the operating surgeon (split surgical package), appropriate modifiers must be appended to indicate separate providers' involvement; documentation of transfer of care is required when applicable.
Total eligible reimbursement for split surgical services must not exceed 100% of the global allowable.
Operational cap on combined reimbursement

ALL of the following

If a conflict arises between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to covered services, the plan documents or provider contract governs; BCBSNM may exercise discretion and reserves the right to request documentation and review claims case-by-case.

Global package coverage criteria

Title of this criteria set corresponds to the policy 'Global package coverage criteria' and reflects BCBSNM global surgical package definitions and application.

Coding, Global Periods, and Modifiers

Global period indicatorsmixed

000	Global Surgery Indicator 000 — day of surgery only, no pre/post period
010	Global Surgery Indicator 010 — day of surgery + 10 days post-op
090	Global Surgery Indicator 090 — 1 pre-op day, day of surgery, +90 days post-op

Modifiers relevant to global period billingModifier

24	Unrelated E/M during postoperative period
25	Significant, separately identifiable E/M on same day as procedure
54	Surgical care only
55	Post-operative management only
56	Pre-operative management only
57	Decision for surgery
58	Staged or related procedure during post-op period
76	Repeat procedure by same physician
77	Repeat procedure by another physician
78	Unplanned return to OR by same physician for related procedure

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Split package reimbursement cap

Policy ruleTotal eligible reimbursement for split surgical services must not exceed 100% of the total global surgical allowable amount.

Definition of split packageA split surgical package occurs when pre-operative and/or post‑operative services are rendered by a physician or other QHP other than the surgeon who performed the procedure.

Modifier requirementAppropriate modifiers must be appended to the same surgical procedure code by each physician or QHP to identify who provided the pre/post‑operative service(s).

Example allocationTypical percentage allocations shown: Modifier 54 = 75%; Modifier 55 = 12.5%; Modifier 56 = 12.5%; Total = 100%.

Documentation and Claim Submission Requirements

Documentation Required

Documentation and claim submission — submit requested documentation and use valid code sets

The Plan may request supporting documentation for claims; providers must submit additional documentation upon request. Providers are responsible for submission of accurate documentation of services performed and for submitting claims using valid HIPAA‑approved code sets and industry coding guidelines. Failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Submit additional documentation upon request to support claim review.
Use valid HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, DRG) and follow industry coding guidelines (AMA CPT, CMS NCCI, UB Editor, CCI edits).
Ensure claims are coded appropriately; claims are subject to code edit protocols and case‑by‑case review.

Definitions

Global surgical package definition

DefinitionThe global surgical package includes all related services and supplies that are routine and necessary to the procedure, rendered by a provider or another physician or other QHP within the same group and/or same specialty and sub‑specialty, preoperative, intra‑operative, and post‑operative to the procedure.

SettingsApplies in any setting including inpatient hospital, outpatient hospital, Ambulatory Surgery Center (ASC), or professional health care provider office.

Who may provide servicesServices may be rendered by the operating provider or another physician/QHP within the same group and specialty/sub‑specialty.

Global Period definition

DefinitionA global period is the time that is pre‑operative, intra‑operative, and post‑operative associated with a surgical procedure.

Pre‑operative visitsBegin after the decision to operate: for major procedures they start with the day before surgery; for minor procedures they begin on the day of surgery.

Intra‑operative servicesServices that are normally a usual and necessary part of a surgical procedure are included in the intra‑operative component of the global period.

Post‑operative visitsFollow‑up visits during the post‑operative period related to recovery from the surgery are included in the global period.