CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP014

Global Surgical Package - Professional Providers

Defines reimbursement and coding rules for the professional global surgical package, including included/excluded services, global periods, modifiers, and split/transfer of services for providers submitting claims to BCBS Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyGlobal Surgical Package - Professional Providers

Policy CodePolicy CPCP014

Change TypeAnnual review (non-material)

Effective DateJun 26, 2023

Next Review Date

Key ActionSubmit accurate supporting documentation upon request and append appropriate modifiers to indicate whether services are part of the global period.

SourceLink

POLICY UPDATE CHANGES

06/21/2023 Annual Review noted in policy update history.

000,010,090CMS-defined values referenced

100%Max split reimbursement

75/12.5/12.5Split percentages (54/55/56)

Jun 26, 2023Plan Effective

Global Surgical Package Coverage Criteria

Global surgical package coverage criteria

Services included in the global surgical package are generally not eligible for separate reimbursement during the global period; specific exclusions, exceptions, and billing rules are described below.

Services included in the global surgical package are not eligible for separate reimbursement during the global period unless an exception is specified.

Included services (examples)

Pre-operative visits: day before surgery for major procedures and day of surgery for minor procedures.
Evaluation and management services for minor surgery on the day of the minor surgery (included in Global Days Values 000-010).
Local infiltration, tumescent anesthesia, metacarpal/metatarsal/digital block, or topical anesthesia.
Intra-operative services usual and necessary to the surgical procedure (e.g., administration of fluids and drugs during an operative procedure).
Immediate post-operative care including dictating operative notes, communication with family/other providers, 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 follow-up E/M visits within the global period.
Postsurgical pain management when performed by the surgeon or same-specialty QHP within the same group.
Routine supplies and miscellaneous services such as dressing changes; removal of sutures, staples, lines, tubes, drains; insertion/irrigation/removal of urinary catheters; routine peripheral IV lines; nasogastric/rectal tubes; tracheostomy tube changes/removal.
Surgical suite or anesthesia equipment and surgical trays (surgical trays are not eligible for separate reimbursement when certain services are performed in a professional office).

Services not included (examples eligible for separate reimbursement)

Initial consultation or evaluation by the surgeon to determine need for major surgery (eligible for separate reimbursement).
Services performed by other physicians unless there is an agreed transfer of care with documentation submitted for eligible reimbursement.
Visits unrelated to the diagnosis for the surgical procedure unless performed due to complications of the surgery.
Treatment of the underlying condition or added courses of treatment not part of normal recovery from surgery.
Diagnostic tests and procedures including diagnostic radiological services.
Clearly distinct surgical procedures during the postoperative period that are not repeat operations or treatments for complications (these may be eligible separately).

Exceptions and special billing rules

A procedure with a Global Days Value of 000, 010, or 090 performed during the postoperative period of another procedure with Global Days Value 010 or 090 by the same surgeon/same specialty provider or another QHP is considered included in the initial procedure's global package unless an appropriate modifier is appended.
A significant and separately identifiable E/M service unrelated to the decision to perform a minor surgical procedure should be reported separately with modifier 25 appended.

Billing and modifier guidance

Modifiers 24 and 25 should not be used during the global period unless documentation supports the visits were separate and unrelated to the surgical procedure.
Incorrect modifier-to-procedure combinations may result in claim denial; corrected claim submission is required for reconsideration.
Split surgical package reimbursement must not exceed 100% of the total global allowable; typical split percentages referenced by the plan should be followed.

Coding — Global Period Indicators and Modifiers

Global period indicatorsmixedCovered

000	Global Days Value indicating no pre- or post-operative days (minor procedures/endoscopies)
010	Global Days Value indicating day of surgery plus 10 postoperative days
090	Global Days Value indicating 1 pre-op day, day of surgery, and 90 postoperative days

Common modifiers referencedModifier

24	Unrelated E/M by same physician 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 postoperative period
76	Repeat procedure by same physician
77	Repeat procedure by another physician
78	Unplanned return to OR by same physician

1–10 of 12

1/2

Global period duration by indicator

000Global Days Value indicating no pre- or post-operative days (day of surgery only).

010Global Days Value indicating day of surgery plus 10 postoperative days (no pre-operative period).

090Global Days Value indicating one pre-operative day, day of surgery, and 90 postoperative days (total global period of 92 days).

Provider Actions — Documentation and Modifier Usage

Documentation Required

Documentation and Record Review

Providers are responsible for submission of accurate documentation of services performed. BCBSOK may request supporting documentation and providers are urged to submit any additional records upon request. Claims are subject to review for coverage, provider contract terms, medical and coding policies, coding software logic, and industry-standard code edit protocols. Providers should submit claims using valid HIPAA-approved code sets and follow accepted coding guidelines (CPT®, HCPCS, ICD-10, NDC, UB, CMS/NCCI, DRG, etc.).

Submit accurate, complete medical records when requested
Use HIPAA-approved code sets and industry-standard coding guidelines
Claims may be reviewed for coverage, contract terms, and coding edits

Billing Rule

Modifier Usage and Claim Corrections

Append appropriate modifiers to CPT/HCPCS codes to indicate whether a service is part of a global period. Several modifiers carry claims logic that can affect reimbursement; an incorrect modifier-to-procedure code combination may trigger a denial. If a claim is denied for an inappropriate modifier, submission of a corrected claim with the proper modifier-to-procedure code combination is required for reimbursement consideration. Do not append Modifier 24 and/or 25 for services during a global period unless the medical record supports that the visit was separate and unrelated to the surgery. Professional providers may append appropriate modifiers to indicate services are not part of a global surgical package when documentation supports separate reimbursement. The list of applicable modifiers is not exhaustive; follow payer and coding guidance for specific modifier usage.

Append modifiers to indicate services that are or are not part of the global period
Incorrect modifier-to-procedure combinations may result in denial — submit a corrected claim for reimbursement consideration
Do not use Modifiers 24/25 during the global period unless documentation supports the service was separate and unrelated
Providers may append appropriate modifiers to seek separate reimbursement when documentation supports exclusion from the global surgical package

Definitions

Global surgical package

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

Included servicesPre-operative visits (as defined by CMS), intra-operative services that are usual and necessary to the procedure, and post-operative follow-up visits related to recovery, plus routine supplies and immediate recovery area care.

Applicable settingsApplies in inpatient hospital, outpatient hospital, Ambulatory Surgery Center (ASC), and professional provider office settings.

Global period

DefinitionThe global period is the timeframe encompassing pre-operative, intra-operative, and post-operative services associated with a procedure, as defined by CMS global period indicators.

Pre-operative periodFor major procedures, begins the day before the surgery; for minor procedures, begins on the day of surgery.

Intra-operative periodServices that are normally a usual and necessary part of the surgical procedure (operative care and immediate recovery).

Post-operative periodFollow-up visits during the postoperative period related to recovery; duration varies by global indicator (e.g., 0, 10, or 90 postoperative days).