CurrentPremera BluecrossPolicy cmi_162302

Global surgery (global surgical package) reimbursement

Defines how Premera Blue Cross determines and reimburses global surgical periods, included/excluded services, and modifier use for professional claims; applies to Premera and affiliated lines of business.

Policy Summary

PayerPremera Bluecross

PolicyGlobal surgery (global surgical package) reimbursement

Policy CodePolicy cmi_162302

Change TypeNo material change

Effective Date

Next Review Date

Key ActionUse the NPFS 'Global Days indicator flag' (CMS) to determine the procedure's global period and apply a single reimbursement for the global package.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

000/010/090Global days indicator flags

10 or 90Postoperative period durations

76/77/78/79Primary modifiers addressed

Multiple productsApplies to

92 daysMajor procedure global period

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Global surgery coverage criteria and modifier rules

Services included and excluded from the global surgical payment:

ALL of the following

ANY of the following
- For major procedures: related preoperative visits after decision to operate (e.g., pre-op visits the day before surgery).
- For minor procedures: the decision to perform the minor procedure is included unless a significant, separately identifiable E&M unrelated to the decision is rendered.
- Intraoperative services that are part of the surgical procedure.
ALL of the following
- All medical and surgical services the surgeon provides during the postoperative period that result from complications which do not require a return to the Operating Room.
- Follow-up visits (E&M, care management, transitional care management) related to recovery from the initial surgery.
- Supplies for postoperative surgical complications or treatments; miscellaneous routine surgical supplies and services (dressing changes, incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, splints; insertion/irrigation/removal of urinary catheters, routine peripheral IV lines, nasogastric and rectal tubes; changes/removal of tracheostomy tubes).
- Postoperative pain management by the surgeon unless the complexity is outside the surgeon's scope.
- Immediate postoperative care, evaluating patients in post-anesthesia recovery, and writing orders.
ALL of the following
- Services of other physicians from the same clinic as the original surgeon (all under the same Tax Identification Number (TIN)) and specialty are included.

ALL of the following

Initial consultation or evaluation to determine need/decision for a major surgical procedure (when identified with appropriate modifier).
Services of other physicians not in the same clinic/specialty/TIN that are related to the procedure (when identified with appropriate modifier).
Visits unrelated to the diagnosis of the procedure (when identified with appropriate modifier).
Treatment of underlying conditions or added courses of treatment not related to the procedure (when identified with appropriate modifier).
Diagnostic tests and procedures (e.g., diagnostic radiologic procedures).
Clearly distinct surgical procedures that occur in the postoperative period that are not re-operations or treatment for complications (when identified with appropriate modifier).

ALL of the following

Modifier 24: append for unrelated E&M during postoperative period by same physician; must be clearly documented (see modifier guidance).
Modifier 25: append when E&M on same day as procedure is significant and separately identifiable beyond routine pre/post care; not for E&M that resulted in decision for major surgery or E&M solely for minor procedure.
Modifiers 54/55/56: use when providers furnish only part of the global package and belong to different practices; each must bill the same procedure code and date and append appropriate modifier.
Modifier 57: append when E&M results in decision for major surgery (90-day global); not for E&M on same day as minor procedure or solely preoperative evaluation.
Modifier 58: append for planned staged or related subsequent procedures by same physician during postoperative period; documentation must show prospective plan; breaks/resets global period; do not bill with 78 or 79.

ALL of the following

Services included in the global surgical payment are not eligible for separate reimbursement unless an appropriate modifier is appended and documentation supports the exception.
When billing for services excluded from the global package, append the appropriate modifier and include documentation to demonstrate why the service is separately billable.

Modifier billing and documentation criteria

Criteria for appending modifiers and documentation needed

ALL of the following

May be appended when the identical service or procedure is repeated by a different physician or qualified healthcare professional for the same patient during the global period (often, but not always, on the same day at a separate distinct subsequent session).
Do not append modifier 77 to a procedure code already appended with modifier 76, 78, or 79.
Documentation in the medical record must indicate the need to repeat the same procedure or service by another provider to support use of modifier 77.

ALL of the following

Must be appended when there is an unplanned return to the operating room for treatment of postoperative complications related to the original surgery or for a surgery related to the original surgery that started the postoperative period occurring within a 10-day or 90-day global period.

Global Period Indicators, Modifiers, and Period Lengths

Global Days indicator flags (NPFS/CMS)mixed

000	No pre/postoperative period (day of procedure only)
010	10-day postoperative period (minor procedures)
090	90-day postoperative period (major procedures)
MMM/XXX/YYY/ZZZ	Special indicators: maternity, XXX (E&M may be inclusive), carrier-determined, add-on related codes

Global period modifiersmixedCovered

modifier 78	Unplanned return to OR for related procedure during global period
modifier 79	Unrelated procedure or service by same physician during postoperative period

Repeat procedure modifiermixedCovered

modifier 77

Repeat procedure by another physician or qualified healthcare professional

inv-06: Major procedure global period length — 92 days (1 preop day + day of surgery + 90 postop days)

Major procedure global period length92 days (1 preoperative day + day of surgery + 90 postoperative days)

Components included1 day before procedure + day of procedure + 90 days after procedure

Reimbursement principleServices related to the original major procedure during this 92-day period are included in the global payment and not separately payable

inv-07: Global period durations — 10-day or 90-day as applicable per CMS NPFS

Global period options10-day or 90-day postoperative periods (minor = 10-day; major = 90-day)

0-day indicatorNo pre/postoperative period (day of procedure only) — global days indicator '000'

Source for assignmentPlan uses CMS NPFS 'Global Days indicator flag' to determine applicable global period

Billing, Modifier Use, and Documentation Requirements

Billing Rule

Determine global period

Use the NPFS 'Global Days indicator flag' to determine the global surgical period for procedures; the global surgical package includes preoperative, intraoperative, and postoperative services and is paid as a single reimbursement for the package.

Global period indicator = NPFS Global Days flag
Single reimbursement for global package applies across settings (inpatient, outpatient, ASC, office)

Documentation Required

Modifier guidance and documentation

Append appropriate modifiers and fully document justification in the medical record when billing services that interact with a global surgical period. Common modifiers include 24, 25, 54, 55, 56, 57, 58, 76, 77, 78 and 79. Documentation must clearly support the reason the service is separate from, not included in, or alters the global package (for example, unrelated problem, significant and separately identifiable E&M, transfer of portions of care, planned staged procedure, repeat service, or unplanned return to OR).

Modifier 24: Unrelated E&M during postoperative global period — document how visit is unrelated; do not use for routine post-op care, suture removal, same-date surgery, complications not requiring OR return.
Modifier 25: Significant, separately identifiable E&M on same day — document the separate, significant service; not for E&M that resulted in decision for major surgery or E&M whose sole purpose was preoperative evaluation for a minor procedure.
Modifiers 54/55/56: Partial global package — use to indicate Surgical Care Only (54), Postoperative Management Only (55), or Preoperative Management Only (56) when care is split across providers in different practices; each provider must bill same surgical code and surgery date and append the appropriate modifier.
Modifier 57: Decision for Surgery — append when E&M results in initial decision for major surgery (90-day global) occurring day before or day of surgery; document decision.
Modifier 58: Staged or related procedure — append for planned subsequent procedures by same physician during postoperative period; documentation must show prospective plan; modifier 58 resets the global period and must not be billed with 78 or 79.

Documentation Required

Modifier 77 guidance

Append modifier 77 when the identical service/procedure is repeated by a different provider for the same patient during the original procedure's global period. Do not append modifier 77 to a service already appended with modifier 76, 78 or 79. Medical record documentation must indicate the reason the procedure was repeated by another provider and support that it is a distinct, repeated service.

Repeat procedure by another provider — use Modifier 77
Do not combine with Modifier 76, 78, or 79 on the same procedure code
Documentation must state clinical rationale for repeating the procedure and identify the different provider

Terms and Modifier Definitions

inv-13: Global surgery / global surgical package — definition and reimbursement principle

DefinitionA global surgical package is the period beginning the day of or the day before a procedure that includes preoperative, intraoperative, and postoperative services for that procedure

Reimbursement principleA single reimbursement is made for all care associated with the global surgical package; related services during the global period are not separately payable

Primary sourcePlan uses the CMS National Physician Fee Schedule (NPFS) 'Global Days indicator flag' to determine global surgery periods

inv-14: XXX / YYY / ZZZ / MMM flags — code-specific flags indicating exceptions (e.g., MMM = maternity)

MMMMaternity indicator — plan-determined handling for maternity-related codes

XXXGlobal periods do not apply; E&M on same day may be considered inclusive to the procedure (with 2026-09-04 guidance allowing modifier 25 when E&M is significant and separate)

YYYCarrier/Plan determined — plan decides whether global periods apply and establishes postoperative period on a case-by-case basis

ZZZAdd-on codes related to a primary service — no postoperative work included; global period assigned to the primary code only

inv-15: Modifier 77 — definition: Repeat Procedure by Another Physician or Other Qualified Healthcare Professional

DefinitionModifier 77 — Repeat Procedure by Another Physician or Other Qualified Healthcare Professional appended when the identical service is repeated by a different provider during the global period

Usage constraintDo not append modifier 77 to a procedure code already appended with modifier 76, 78, or 79

Documentation requirementMedical record must indicate the need to repeat the same procedure or service by another provider

inv-16: Modifier 78 — definition: Unplanned Return to the Operating Room by the Same Physician or Other Qualified Healthcare Professional Following Initial Procedure

DefinitionModifier 78 — Unplanned Return to the Operating Room by the Same Physician or Other Qualified Healthcare Professional following the initial procedure for a related procedure during the postoperative period

Applicable periodsUsed when return to OR occurs within a 10-day or 90-day global period

Documentation requirementMedical record must support the need for an unplanned return to the OR for a related procedure

inv-17: Modifier 79 — definition: Unrelated Procedure or Service by the Same Physician or Other Qualified Healthcare Professional During the Postoperative Period

DefinitionModifier 79 — Unrelated Procedure or Service by the Same Physician or Other Qualified Healthcare Professional during the postoperative period

ApplicabilityAppropriate for additional procedures during a 10-day or 90-day global period when the procedure is unrelated to the original surgery; not appropriate following procedures with a 0-day global period

Usage constraintDo not append modifier 79 to a service/procedure code already appended with modifier 58 or 78; documentation must clearly indicate the procedure is unrelated

OpenPayer

Global surgery (global surgical package) reimbursement

Services Included / Excluded and Modifier Rules

Global Period Indicators, Modifiers, and Period Lengths

Billing, Modifier Use, and Documentation Requirements

Terms and Modifier Definitions