CurrentHighmark Blue Cross Blue Shield WnyPolicy G-06041

Global Surgical Package reimbursement

This policy governs reimbursement rules for the global surgical package for Highmark BCBS members in Medicaid Managed Care, HARP, Child Health Plus, and Essential Plan programs, specifying included and separately reimbursable services and coding guidance.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyGlobal Surgical Package reimbursement

Policy CodePolicy G-06041

Change TypeClarified languagenon‑material updates

Effective DateJan 30, 2023

Next Review Date

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence; global package allowed unless contracts indicate otherwise.

SourceLink

POLICY UPDATE CHANGES

Updated policy with minor language changes for clarity and updated lists of services included and separately reimbursable within the Global Surgical Package.

MMC, HARP, CHPlus, EPprograms covered

0,10,90postop periods

XXX/YYY/ZZZCMS indicators followed

Providedseparately reimbursable list

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Global Surgical Package coverage criteria

The health plan reimburses the global surgical package per CMS indicators; specified components are included and specific services are separately reimbursable.

Policy scope: The health plan allows reimbursement for the global surgical package unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise; the plan follows CMS global surgery indicator codes (including supplementary indicators XXX, YYY, and ZZZ) and applies to procedures with postoperative periods of 0, 10, or 90 days.

Included in the Global Surgical Package

Preoperative services rendered after the decision is made to operate: beginning with the day before surgery for major procedures; beginning with the day of surgery for minor procedures.
Evaluation and management (E/M) services rendered after the decision for surgery has been made.
Intraoperative services that are normally a usual and necessary part of a surgical procedure, including miscellaneous surgical services and supplies (e.g., surgical kits).
Fluid and drug administration services: therapeutic drugs; prophylactic drugs; local anesthetic injections; anesthetic blocks or agents; topical anesthesia; unspecified/unclassified drug codes administered by the operating provider.
Intraoperative pain management and devices, and moderate sedation.
Visits during the postoperative periods that are related to recovery from the surgery, regardless of place of service, including clinic fees or other facility fees reported on a UB-04 associated with typical postoperative care.
Medical or surgical services due to postoperative complications that do not require additional trips to the operating room and are not categorized as a hospital-acquired condition (HAC) or present on admission (POA).
Postsurgical pain management provided by the surgeon.

Separately reimbursable (not included in the global package)

The initial consultation or evaluation by the surgeon to determine the need for a major surgical procedure.
Services of other physicians, except where the surgeon and the other physician(s) agree on the transfer of care documented by a letter or annotation in the discharge summary, hospital record, or ASC record.
Visits during the postoperative period that are unrelated to the diagnosis of the surgery, unless they occur due to complications of the surgery.
Treatment for an underlying condition or an added course of treatment that is not part of the normal recovery from surgery.
Diagnostic tests and procedures.
Clearly distinct surgical procedures during the postoperative period that are not re-operations or treatment for complications.

Unlisted surgical procedures (YYY)

Unlisted surgical procedures are reviewed on an individual claim basis; claims must include a written description, office notes, and an operative report for consideration during review.

Add-on surgical procedures (ZZZ)

Global surgical period for an add-on surgical procedure is based on the primary surgical code (the add-on is included in the global period of the primary service).

Coding and modifiers

Standard correct coding applies; providers must use applicable HIPAA-compliant modifiers for any services provided during the postoperative period.

Coding and Global Surgery Indicators

Global surgery indicator and related codesmixed

XXX	Codes that the global surgery concept does not apply
YYY	Unlisted surgical procedures; health plan/MAC determines global period (0, 10, or 90 days)
ZZZ	Add-on codes included in the global period of the primary service

Global period lengths

0-day global periodUsed for minor procedures where no postoperative days are included; applicable when CMS/global indicator assigns 0-day period.

10-day global periodUsed for minor procedures of greater complexity that include a 10-day postoperative period as indicated by CMS/global indicators.

90-day global periodUsed for major procedures; includes 90 postoperative days and encompasses preoperative, intraoperative, and postoperative services as part of the global package.

Authorization and Provider Billing Actions

Prior Authorization

Authorization, medical necessity, documentation, and billing requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; the global surgical package is allowed unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. Claims must use proper billing and submission guidelines with industry‑standard codes (CPT, HCPCS, revenue codes) and be fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement.

Follow authorization and medical necessity requirements for the procedure and member's state of residence.
Use appropriate CPT/HCPCS/revenue codes on all claims and ensure documentation in the medical record and/or office notes supports the billed services.
Be aware the global package is allowed unless superseded by provider, state, federal, or CMS contracts/requirements.
Noncompliance with coding/billing guidelines may lead to claim denial, payment recovery/recoupment, or reimbursement adjustment.

Definitions Related to Global Surgery

Global surgical package — definition

DefinitionThe global surgical package includes all necessary services normally furnished by a surgeon before, during, and after a procedure.

ScopeIncludes preoperative evaluation and management related to the decision to operate, intraoperative services and supplies, and postoperative visits related to recovery.

ApplicabilityApplies unless provider, state, federal, or CMS contracts or requirements indicate otherwise.

Major procedures (90-day global period)

90-day global codesCodes classified as major procedures have a 90-day global surgical period.

InclusionPreoperative, intraoperative, and postoperative care for major procedures are included in the 90-day global period.

ExamplesMajor procedures are identified by CMS/global surgery indicators (codes classified as 90-day).

Minor procedures (0-day or 10-day global periods)

0-day global codesCodes classified as minor procedures with a 0-day global period (no postoperative days included).

10-day global codesCodes classified as minor procedures with a 10-day global period for greater complexity.

DeterminationDesignation as 0- or 10-day is based on procedure complexity per CMS/global surgery indicators.

Plan/MAC-determined global period (YYY)

YYY codesUnlisted or specified codes for which the health plan or MAC determines the global period; the global period for these codes will be 0, 10, or 90 days.

Review processGlobal period for YYY codes is assigned by plan/MAC on a claim-by-claim or code determination basis.

ApplicabilityUsed when CMS indicators do not specify a definitive global period for the code.

Add-on codes (ZZZ)

Add-on codes (ZZZ)Add-on codes are related to another service and are always included in the global period of the primary service.

Payment implicationAdd-on procedures are not assigned a separate global period; they follow the primary procedure's global period for postoperative coverage.

Coding noteProviders should report add-on codes with the primary procedure; global surgical period rules apply based on the primary code.

OpenPayer

Global Surgical Package reimbursement

Global Surgical Package Coverage Criteria

Coding and Global Surgery Indicators

Authorization and Provider Billing Actions

Definitions Related to Global Surgery