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) and explains which services are included, excluded, and when modifiers permit separate payment. Applies to claims adjudicated by BCBSNM.
No material clinical or coverage changes in this revision.
Global Surgical Package Coverage
Global package coverage criteria
Covered when services meet the conditions below; certain services are included in the global surgical package and are not separately reimbursable unless specific exceptions or modifiers apply.
Included services (examples)
- Pre‑operative visits beginning the day before surgery for major procedures and the day of surgery for minor procedures.
- Immediate post‑operative care, including dictation of operative notes, communications with family/physicians, writing orders, and evaluation in the post‑anesthesia recovery area.
- Post‑operative follow‑up care during the designated global period related to recovery from the surgery, including routine follow‑up E/M visits occurring within the global period (except for significant, separately identifiable E/M services unrelated to the decision to perform a minor procedure which may be billed with modifier -25).
- Postsurgical pain management when performed by the surgeon, same specialty/subspecialty physician, or other QHP within the same group.
- Routine supplies and miscellaneous services such as dressing changes; local incisional care; removal of operative packs; removal of cutaneous sutures and staples; insertion/irrigation/removal of urinary catheters; routine peripheral IV lines; nasogastric/rectal tubes; changes/removal of tracheostomy tubes; and surgical trays when performed in a professional office setting are included and not separately reimbursable unless specifically excluded.
Services excluded from the global package (examples)
- Initial consultation or evaluation by the surgeon to determine the need for major surgery — not included unless transfer of care is documented and supports separate reimbursement.
- Services performed by other physicians, except when a documented transfer of care supports separate reimbursement.
- Visits unrelated to the diagnosis for the surgical procedure, unless performed due to complications of the surgery.
- Diagnostic tests and procedures, including diagnostic radiological services.
- Treatment of the underlying condition or an added course of treatment not part of normal recovery from surgery.
- Clearly distinct surgical procedures during the post‑operative period that are not repeat operations or treatment for complications (may be eligible separately when distinct).
- Treatments for postoperative complications that require a return to the operating room (these are not included and may be separately reimbursable).
- When a less extensive procedure fails and a more extensive procedure is required, the second procedure may be eligible for separate reimbursement.
- Immunosuppressive therapy for organ transplants and critical care services unrelated to the surgical procedure where a critically ill patient requires constant attendance — not included in the global package.
Conditions for separate reimbursement and modifier use
- A procedure with global days 000, 010, or 090 performed during the post‑operative period of another procedure is considered included in the initial procedure’s global package when both procedures are reported by the same surgeon, same specialty provider or another QHP, unless an appropriate modifier is appended.
- A significant, separately identifiable E/M service unrelated to the decision to perform a minor surgical procedure may be reported separately if documented and modifier -25 is appended.
- Modifiers must be correctly appended to indicate whether services are inside or outside the global period; inappropriate modifier‑to‑procedure code combinations may result in claim denials and corrected claims will be required.
- When pre‑operative and/or post‑operative services are rendered by different providers (split surgical package), appropriate modifiers must identify provider roles and the combined reimbursement for split services must not exceed 100% of the total global surgical allowable amount.
Global Period Codes and Modifiers
| 000 | Global surgery indicator — no pre/post-operative days; minor procedures (no separate pay for day of surgery visit). |
| 010 | Global surgery indicator — day of surgery plus 10 post-op days (total 11 days). |
| 090 | Global surgery indicator — includes one day pre-op and 90 post-op days (total 92 days). |
| 24 | Unrelated E/M service 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 |
Documentation, Claims, and Modifier Handling
Documentation and review
Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims using valid HIPAA-approved code sets and to code appropriately per industry-standard guidelines (UB, AMA CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI, etc.). Claims are subject to review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, BCBSNM may require supporting documentation; providers should submit additional documentation promptly and are responsible for the accuracy of submitted information.
Modifier claim denials
Modifiers should be appended to CPT/HCPCS codes to indicate whether a service is part of a global period. Several modifiers have claims logic that may impact reimbursement. Claim submissions may be denied if an inappropriate modifier-to-procedure code combination is used. In such cases, a corrected claim with the proper modifier-to-procedure code combination will be required for reimbursement consideration. Specifically, modifiers 24 and 25 must not be appended to services during a global surgical period when the medical records do not support that the visits were separate and unrelated. Professional providers should append an appropriate modifier to indicate a service is not part of a global surgical package when documentation supports separate reimbursement. This is not an all-inclusive list of modifiers that may affect claim processing.
- Incorrect modifier-to-procedure code combinations may result in claim denials; corrected claims will be required.
- Do not append Modifier 24 or 25 during a global period unless documentation shows the service was separate and unrelated.
- Append appropriate modifiers to indicate services are not part of a global surgical package when supported by medical records.
Key Definitions
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