CurrentBlue Cross Blue Shield - TexasPolicy CPCP014

Global Surgical Package - Professional Provider

Defines billing and coding rules for the global surgical package for professional provider claims, describing included/excluded services, global periods, modifiers, and reimbursement considerations affecting providers billing Blue Cross and Blue Shield of Texas members.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyGlobal Surgical Package - Professional Provider

Policy CodePolicy CPCP014

Change TypeAdded code guidanceeditorial updates

Effective DateApril 15, 2025

Next Review Date

Key ActionSubmit supporting documentation promptly when requested; corrected claims required for inappropriate modifier-to-procedure combinations.

SourceLink

POLICY UPDATE CHANGES

New code section added for G0559.

Grammatical updates and Additional Resources updated; References updated.

000, 010, 090Global Days Values

G0559New HCPCS add-on

100%Split reimbursement cap

CPCP014Policy ID

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Global Surgical Package Criteria

Services included, excluded, and modifier-related rules governing separate reimbursement within global periods.

Included Services: The professional global surgical package includes the following services when rendered by the surgeon or other qualified health care professional (QHP) in the same group/specialty: pre-operative visits (beginning the day before surgery for major procedures and the day of surgery for minor procedures); E/M services for minor surgery on the day of the procedure when included in Global Days Value 000–010; local infiltration, tumescent, digital/metacarpal/metatarsal blocks, or topical anesthesia; intra-operative services usual and necessary to the procedure (including administration of fluids and drugs during the operative procedure); immediate post-operative care (including dictating operative notes, communicating with family/other physicians/QHPs); writing orders; evaluation in the post-anesthesia recovery area; post-operative follow-up care during the designated global period related to recovery (routine follow-up E/M visits occurring within the global period); surgical suite or anesthesia equipment; postsurgical pain management when performed by the surgeon or same-specialty QHP within the same group; supplies except those identified as exclusions; and miscellaneous routine post-operative items (dressing changes; local incisional care; removal of operative pack, sutures/staples, lines/wires/tubes/drains/casts/splints; urinary catheter insertion/irrigation/removal; routine peripheral IV lines; nasogastric and rectal tubes; changes/removal of tracheostomy tubes).

Excluded Services: Services not included in the global surgical package and generally eligible for separate reimbursement (when applicable) include: initial consultation or evaluation to determine need for major surgery; services performed by other physicians unless there is documented transfer of care (documentation should be submitted for eligible reimbursement); visits unrelated to the surgical diagnosis unless due to surgical complications; treatment of the underlying condition or additional treatment not part of normal recovery; diagnostic tests and procedures (including diagnostic radiology); clearly distinct surgical procedures during the post-operative period that are not repeat operations or treatment for complications; treatments for postoperative complications requiring return to the operating room; when a less extensive procedure fails and a more extensive procedure is required (the second procedure may be eligible separately); immunosuppressive therapy for organ transplants; and critical care services unrelated to the surgical procedure (e.g., critically ill patients requiring constant physician attendance).

Global Period Durations: CMS-defined Global Days Values apply: 000 (day of surgery only; no pre- or post-operative days; visits on day of procedure generally not payable separately), 010 (day of surgery plus 10 days after; no pre-operative period; total global period = 11 days), and 090 (major surgery: one day pre-operative, day of surgery, and 90 days after; total global period = 92 days). Services provided after the global period may become eligible for separate reimbursement based on these post‑operative day counts. Note: when a procedure with global days 000, 010, or 090 is performed during the post-operative period of another procedure with 010 or 090 and both procedures are reported by the same surgeon/specialty provider or another QHP, the second procedure is considered included in the initial procedure's global package unless an appropriate modifier is appended.

Modifier Rules and Separate Reimbursement: Modifiers must be appended as appropriate to indicate the relationship of a service to a global period. Modifier guidance includes: - Modifier 24: unrelated E/M service by same physician/QHP during postoperative period; - Modifier 25: significant, separately identifiable E/M service on same day of procedure; - Modifiers 54/55/56/57/58/76/77/78/79/FT: used for surgical care only, post‑operative only, pre‑operative only, decision for surgery, staged/related procedures, repeat procedures, unplanned return to OR, unrelated procedures, and unrelated critical care E/M, respectively. Inappropriate modifier-to-procedure code combinations can result in claim denials; documentation must support use of Modifier 24 or 25 during the global period (unrelated or significant/separately identifiable service).

G0559 — Special Post‑operative Code: HCPCS add-on code G0559 describes time and/or resources associated with post‑operative care during the 90‑day global period when the post‑operative care is provided by a physician or other QHP who did not perform the surgical procedure, is not in the same group practice, and no formal transfer of care has been established. G0559 is reported in addition to an office or outpatient E/M code without modifier 55. Providers should follow documentation and modifier rules when billing G0559 to support separate reimbursement.

Codes, Modifiers, and Reimbursement Limits

Global package-related codes and modifiersHCPCS | Modifier | mixedCovered

G0559	HCPCS add-on code for time/resources associated with postoperative care during 90-day global period by a physician or QHP not in same group and no formal transfer of care
Modifier 24	Unrelated E/M service by the same physician or other QHP during a postoperative period
Modifier 25	Significant, separately identifiable E/M service by the same physician or other QHP on the same day of the procedure or other service
Modifiers 54/55/56/57/58/76/77/78/79/FT	Various modifiers for surgical care only, post-operative management only, pre-operative management only, decision for surgery, staged/related procedures, repeats, unplanned return to OR, unrelated procedures, and unrelated critical care E/M visits during a postoperative period

Split Surgical Package Reimbursement Cap

Reimbursement capEligible reimbursement for a split surgical service must not exceed 100% of the total global surgical allowable amount.

DefinitionA split surgical package occurs when pre‑operative and/or post‑operative services are rendered by a physician or QHP other than the surgeon performing the procedure.

Modifier requirementAppropriate modifiers should be appended to the same surgical procedure code by each physician or QHP to identify who provided the service(s).

Example percentage allocationPolicy gives example allocations: Modifier 54 = 75%, Modifier 55 = 12.5%, Modifier 56 = 12.5% (total = 100%).

Documentation, Claims, and Modifier Risk Guidance

Documentation Required

Documentation and Claims Review — Submit Supporting Documentation Upon Request

Claims are subject to code edit protocols and claim review. Upon request, the provider is urged to submit any additional supporting documentation; providers are responsible for submission of accurate documentation of services performed and should code claims using valid code combinations and industry-standard coding guidelines. Review may consider benefit coverage, provider contract language, medical policies, CPCPs, and coding software logic.

Denial Risk

Modifier Claim Denial Risk — Corrected Claim Required for Inappropriate Modifier Use

Claims may be denied when an inappropriate modifier-to-procedure code combination is submitted; if denied for this reason, a corrected claim with the proper modifier-to-procedure code combination is required for reimbursement consideration.

Modifiers should be appended to indicate whether a service is part of the global period; modifier claim logic can impact reimbursement.
Modifier 24 and/or 25 should not be appended during the global period unless medical records support the service was separate and unrelated.

Key Definitions

Global Period — Definition

DefinitionGlobal period is the time that is pre‑operative, intra‑operative, and post‑operative.

Source of durationsThe Plan's claims payment systems utilize the CMS‑defined global periods, which vary according to the procedure being performed.

Pre‑operative visitsPre‑operative visits begin either the day before surgery for major procedures or the day of surgery for minor procedures.

Post‑operative visitsPost‑operative visits are follow‑up visits during the post‑operative period related to recovery from surgery.

Global Surgical Package — Definition

Global surgical package — definitionAll related routine and necessary services and supplies for preoperative, intra‑operative, and postoperative care rendered by a provider or another physician or other QHP within the same group and/or same specialty/sub‑specialty for a procedure.

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

InclusionsReimbursement for postoperative services are included in the global professional reimbursement rate; follow‑up care is rendered in the professional provider office setting.

Provider responsibilityProviders are responsible for informing members how and where to access postoperative care as part of hospital discharge planning.

OpenPayer

Global Surgical Package - Professional Provider

Global Surgical Package Coverage Criteria

Codes, Modifiers, and Reimbursement Limits

Documentation, Claims, and Modifier Risk Guidance

Key Definitions