Covered when the following criteria determine whether services are part of the professional global surgical package or may be eligible for separate reimbursement.
Global period determination: Plan uses CMS-defined Global Days Values (000, 010, 090) to determine the applicable global period for a procedure; the global period calculation and criteria (no pre/post days for 000; day of surgery +10 days for 010; 1 pre-op day, day of surgery, +90 post-op days for 090) govern inclusion in the global surgical package.
See Global Period values and calculations.
Included services (typically included unless criteria below are met)
Pre-operative visits: start the day before surgery for major procedures and the day of surgery for minor procedures.
Intra-operative services and related anesthesia/local infiltration and administration of fluids/drugs are included in the package and are not separately reimbursable.
Immediate post-operative care including dictation of operative notes, communicating with family/other clinicians, writing orders, and evaluation in the post-anesthesia recovery area.
Post-operative follow-up E/M visits related to recovery during the designated global period are included unless they meet the separate-reporting criteria below.
Services that may be separately reimbursable (exceptions/conditions)
Clearly distinct surgical procedures during the post-operative period that are not repeat operations or treatment for complications may be eligible for separate reimbursement with documentation.
Treatment of postoperative complications requiring a return to the operating room may be eligible for separate reimbursement.
If a less extensive procedure fails and a more extensive procedure is required, the second procedure may be eligible for separate reimbursement.
Services performed by other physicians are excluded from the operating surgeon's global package unless a formal transfer of care is documented; when care is transferred, submit documentation for eligibility.
Post-operative E/M separate reporting rule: A post-operative E/M visit within the global period is included unless it is a significant, separately identifiable service (reportable with modifier 25) or is unrelated to the procedure (reportable with modifier 24); medical record must support the use of these modifiers.
Do not append modifiers 24/25 when documentation does not support separate or unrelated visits.
Split/split care reimbursement limit: When pre-operative and/or post-operative services are rendered by different practitioners (split/split care), combined eligible reimbursement for the split surgical package must not exceed 100% of the total global allowance; appropriate modifiers must be appended per billing guidance.
Split surgical package maximum = eligible reimbursement ≤ 100% of total global allowable.
G0559 reporting allowance: HCPCS add-on code G0559 may be reported in addition to an office or outpatient E/M code when post-operative care is provided by a physician or QHP who is not the operating provider and not in the same group and no formal transfer of care exists; when reporting G0559, do not append modifier 55 to the E/M code.
Operational reporting requirement for post-operative care by non-operating provider.
Modifier use and denial risk: Append appropriate modifiers to indicate whether a service is part of the global period; inappropriate modifier-to-procedure combinations may result in claim denial and require corrected claim resubmission.
Refer to list of applicable modifiers (24, 25, 54, 55, 56, 57, 58, 76, 77, 78, 79, FT) and ensure documentation supports modifier use.
Documentation requirement: The Plan may request supporting documentation for services billed during the global period; providers must submit additional records upon request to support separate reimbursement eligibility.
Failure to provide requested documentation may impact reimbursement.