CurrentPremera BluecrossPolicy N/A

Global Surgery / Global Surgical Package

Defines how Premera Blue Cross and affiliated plans determine global surgical periods and which services are included or excluded from the global surgical payment for professional claims; applies to participating providers submitting CMS-1500/837P professional claims.

Policy Summary

PayerPremera Bluecross

PolicyGlobal Surgery / Global Surgical Package

Policy CodePolicy N/A

Change TypeClarifications and minor additions

Effective DateN/A

Next Review DateN/A

Key ActionUse the CMS NPFS Global Days indicator flag to determine whether a procedure has a specified global period and bill accordingly.

SourceLink

POLICY UPDATE CHANGES

Added statement regarding services from providers under the same Tax ID# as the primary surgeon and clarification on how to bill services unrelated to the original surgery.

Inserted new paragraphs and sections for Modifiers 76 and 77 to address repeated procedures by the same or another provider.

Multiple Procedure Reduction section updated and links added to CMS National Physician Fee Schedule; identified procedure flag '2' for multiple procedure reductions.

Added clarifications and minor edits across many modifier sections (24, 25, 54–59, 76–79) including documentation expectations and examples when modifiers apply or should not be appended.

000 / 010 / 090Recognized CMS global days indicators covered (0, 10, 90 days)

92 daysTotal global period for major procedures

11 days

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Total global period for minor procedures

IncludedServices included in global payment

ExcludedServices eligible for separate reimbursement

24,25,54–59,76–79Modifier sections addressed

Services Included in and Excluded from Global Surgical Payment

inv-01: Bundled vs separately payable services

The Plan determines which services are bundled into the global surgical payment and which are eligible for separate reimbursement as follows:

ALL of the following

For major surgical procedures: related preoperative visits after the decision to operate (e.g., pre‑operative visits the day before surgery).
For minor procedures: the decision to perform the minor procedure is included unless a significant, separately identifiable E&M service unrelated to the decision for the minor surgery is rendered.
Intraoperative services that are part of the surgical procedure.
All medical and surgical services the surgeon provides during the postoperative period that result from complications that do not require a return to the operating room.
Services of other physicians from the same clinic as the original surgeon (all under the same Tax Identification Number (TIN)) and specialty.
Follow‑up visits in the postoperative period related to recovery from the initial surgery (e.g., E&M, care management, transitional care management).
Supplies for postoperative surgical complications or treatments and miscellaneous postoperative 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 scope of the surgeon.
Local infiltration, digital blocks, or topical anesthesia; immediate postoperative care; writing orders; evaluating patients in post‑anesthesia recovery; other medical/surgical services required by the surgeon during the postoperative period.

ANY of the following

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

inv-02: Modifier-based coverage criteria

Modifiers may justify separate payment during a global surgical period when documentation and the nature of the service meet the policy criteria below:

ALL of the following

Append the appropriate CPT modifier to indicate the relationship of the service to the global surgical package; payment for the service during the global period is contingent on the modifier and supporting documentation in the medical record.
Documentation must support the medical necessity and the modifier’s rationale (e.g., unrelated E&M, decision for surgery, staged procedure, repeat procedure, return to OR).

Examples of specific modifier applications

Modifier 24 — Unrelated E&M service by the same physician in the postoperative period: valid when the E&M visit is unrelated to the original procedure and documentation supports the unrelated nature; policy clarifications specify examples when modifier 24 should not be appended.

Codes, Modifiers, and Procedure Flags

Global surgery modifiersModifier

24	Modifier 24 - Unrelated E&M Service by the Same Physician in the Postoperative Period
25	Modifier 25 - Significant, Separately Identifiable E&M Service on the Same Day of a Procedure
54	Modifier 54 - Surgical Care Only
55	Modifier 55 - Postoperative Management Only
56	Modifier 56 - Preoperative Management Only
57	Modifier 57 - Decision for Surgery
58	Modifier 58 - Staged or Related Procedure During Postoperative Period
76	Modifier 76 - Repeat Procedure by Same Provider
77	Modifier 77 - Repeat Procedure by Another Provider
78	Modifier 78 - Unplanned Return to the OR for Related Procedure

1–10 of 11

1/2

Multiple procedure reduction indicatormixed

Multiple Procedure Flag '2'

Identifies procedures subject to multiple procedure reductions per CMS NPFS

Global days indicator flags — NPFS reference

Source of flagsPlan uses CMS National Physician Fee Schedule (NPFS) 'Global Days' indicator flags to determine global periods for procedures

Common flag values000 (no pre/postoperative days), 010 (10-day postoperative; total 11 days), 090 (90-day postoperative; total 92 days)

Other NPFS indicatorsMMM (maternity — carrier/Plan determined); XXX (global periods do not apply); YYY (carrier/Plan determined case-by-case); ZZZ (add-on codes — no postoperative work)

Usage guidanceUse the NPFS flag for each CPT/HCPCS code to identify whether preoperative or postoperative periods apply and the applicable length of the global period

Reference link inclusionPolicy includes link to CMS NPFS as the authoritative source for flag values and updates

Billing, Modifier Use, and Documentation Requirements

Note

Global days indicator usage

The Plan uses the CMS National Physician Fee Schedule (NPFS) "Global Days indicator flag" to determine whether a procedure code has a global surgery period and which global period applies. Providers must reference the current NPFS global days indicator to identify the applicable global period for professional (CMS-1500 / 837P) claims. Global days flags and meanings include: 000 (no pre/post period; visit on day of procedure not payable separately), 010 (10-day postoperative period; day of procedure included; total 11 days), 090 (90-day postoperative period; includes one day preoperative; total 92 days), and special flags such as MMM (maternity — Plan determined), XXX (global periods do not apply), YYY (Carrier/Plan determined), and ZZZ (add-on codes; no postoperative work).

Providers must use the CMS NPFS Global Days indicator flag to determine global period applicability.
000 — No pre/postoperative period; day of procedure visit not separately payable.
010 — 10-day postoperative period (total 11 days including day of procedure); related services during this period are included in the global payment.
090 — 90-day postoperative period (includes 1 day preop and 90 days postop; related services included in global payment).
MMM/XXX/YYY/ZZZ — Special handling per NPFS and this Plan; see Maternity Services policy for MMM.

Key Terms and Modifier Definitions

Global surgery — definition

DefinitionGlobal surgical package (global surgery) is a period that starts the day of or the day before the procedure and includes all necessary preoperative, intraoperative, and postoperative services normally furnished by a provider; a single reimbursement is made for all care associated with the package

Applicable settingsApplies to procedures performed in inpatient/outpatient hospital, ambulatory surgery center, or provider office settings

Determination sourceThe Plan primarily uses the CMS NPFS 'Global Days' indicator flag to determine whether a procedure has a specified global period

Billing implicationWhen a procedure has a global package, related services furnished during the global period are bundled into the single reimbursement and are not separately payable unless a specific modifier or exception applies

Global days indicator flags — meanings

Policy Summary

PayerPremera Bluecross

PolicyGlobal Surgery / Global Surgical Package

Policy CodePolicy N/A

Change TypeClarifications and minor additions

Effective DateN/A

Next Review DateN/A

Key ActionUse the CMS NPFS Global Days indicator flag to determine whether a procedure has a specified global period and bill accordingly.

SourceLink

On This Page

Treatment for postoperative complications that necessitate a return to the operating room.

Immunosuppressive therapy for organ transplants.

Critical care services (CPT 99291, 99292) unrelated to the surgery.

Failed less extensive initial procedure(s) which subsequently require a more extensive procedure when identified with an appropriate modifier.

Modifier 25 — Significant, separately identifiable E&M service on the same day as a procedure: valid when documentation supports a separate and distinct E&M service; appending modifier 25 does not automatically allow payment unless documentation substantiates the service.

Modifiers 54/55/56 — Partial global package services: use when only surgical care, postoperative management only, or preoperative management only is provided; emergency department providers performing minor or major surgery in the ED may use Modifier 54 where appropriate.

Modifier 57 — Decision for surgery: use when an E&M visit results in the initial decision to perform major surgery and documentation supports the decision; includes 90‑day global period considerations for major surgery.

Modifier 58 — Staged or related procedure during the postoperative period: use when an anticipated, pre‑planned, or more extensive subsequent procedure is performed and documentation indicates plans to return to the OR when applicable.

Modifiers 76/77 — Repeat procedures: use Modifier 76 for repeat procedures by the same provider and Modifier 77 for repeat procedures by another provider; documentation must support the need to repeat the procedure and the policy cross‑references Modifier 76/77 payment guidance.

Modifier 78 — Unplanned return to the operating room for a related procedure: use when an unplanned return to the OR is required; documentation should support the unplanned nature and relationship to the original procedure.

Modifier 79 — Unrelated procedure or service during the postoperative period: use when the procedure is unrelated to the original surgery and documentation supports that the procedure is unrelated; policy includes clarifications regarding billing when services are furnished by providers under the same TIN as the primary surgeon.

Billing Rule

Modifier billing and documentation requirements

Append the appropriate CPT modifier when billing services that are separate from, alter, or transfer parts of a global surgical package. Documentation in the medical record must justify modifier usage and clearly support why the service is separate, unrelated, repeated, transferred, staged, or resulted in a decision for surgery. The Plan will deny or bundle services when modifier use is not supported by documentation.

Modifier 24 — Unrelated E&M by the same physician during postoperative period: append when the E&M is unrelated to the condition that required the surgery; document why visit is unrelated. Do NOT append for surgical complications not requiring OR return, suture removals/wound care, services on same date as surgery, or routine postoperative exams.
Modifier 25 — Significant, separately identifiable E&M on same day: append when E&M is above and beyond usual pre/post care; documentation must support distinct, significant service. Not appropriate when E&M resulted in decision to perform major surgery (90-day global) or when visit is solely for a minor procedure.
Modifiers 54/55/56 — Partial global package: use when providers from different practices supply only surgical (54), postoperative (55), or preoperative (56) portions of the global package. Each provider must bill the same procedure code and surgery date and append the appropriate modifier. 54 and 55 do not apply to assistant-at-surgery services or ASC facility fees.
Modifier 57 — Decision for surgery: append when an E&M visit results in the initial decision to perform major surgery (90-day global); document decision in the medical record. Do not append for E&M on same day as a minor procedure or for E&M solely as a preoperative evaluation.
Modifier 58 — Staged or related subsequent procedure by same physician during postoperative period: append when the subsequent procedure was prospectively planned; documentation must show intent to return to OR. Modifier 58 breaks/terminates the initial global period and resets the global calculation. Do not bill 58 with 78 or 79 on the same service.
Modifier 78 — Unplanned return to OR for related procedure: append when same physician returns patient to OR for treatment of postoperative complications or a related procedure within 10- or 90-day global period; documentation must support need. Unrelated unplanned returns do not restart global periods.
Modifier 79 — Unrelated procedure by same physician during postoperative period: append when the subsequent procedure during a 10- or 90-day global is unrelated to the original surgery (typically different anatomic site); document that the procedure is unrelated. Not appropriate for procedures following a 0-day global period. Do not append 79 with 58 or 78 on the same service.

Documentation Required

Repeated procedures (Modifiers 76/77)

When the same procedure must be repeated during the global period, append the correct repeat-procedure modifier and include documentation explaining the clinical necessity for the repeat service and why it is distinct from the initial procedure.

Modifier 76 — Repeat procedure by same provider: append when the identical service/procedure is repeated by the same physician for the same patient in a separate subsequent session during the global period. Do NOT use for codes that already indicate multiple procedures/sessions in their descriptors. Do not append 76 if 77, 78 or 79 are already appended to the same procedure code.
Modifier 77 — Repeat procedure by another provider: append when the identical service/procedure is repeated by a different physician or qualified healthcare professional for the same patient in a separate subsequent session during the global period. Do not append 77 if 76, 78 or 79 are already appended to the same procedure code.
Documentation must indicate the medical necessity and distinct timing/ circumstances requiring repetition and must support choice of 76 versus 77.

000 - No global period

No preoperative or postoperative period; a visit on day of procedure is not payable separately; global period equals day of procedure

010 - Minor proceduresNo preoperative period; visit on day of procedure included; total global period = 11 days (day of procedure + 10 postoperative days); services related to the minor procedure during these 11 days are bundled

090 - Major surgical proceduresIncludes one-day preoperative period and day of procedure; visit on day of procedure included; total global period = 92 days (1 day before + day of + 90 postoperative days); related services during this period are bundled

Other indicatorsMMM (maternity — usual global periods do not apply), XXX (global periods do not apply), YYY (carrier/Plan determined case-by-case), ZZZ (related/add-on codes with no postoperative work)

Global Days flag (CMS NPFS)

NameGlobal Days indicator flag (CMS National Physician Fee Schedule)

PurposeIdentifies whether a procedure code has a specified global surgical period and the length of pre/postoperative coverage

How to useRefer to the NPFS flag for each CPT/HCPCS code to determine applicable global days before applying modifiers or determining separate payment eligibility

Modifier 79 — unrelated procedure during global period

DefinitionModifier 79 is appended when a procedure performed during the global period is unrelated to the original surgery and the medical record documentation supports that the subsequent procedure is unrelated

Documentation requirementMedical records must support that the later procedure is unrelated to the original surgery to justify separate billing with modifier 79

Billing considerationsPolicy includes clarification on billing when unrelated services are provided by providers under the same Tax ID# as the primary surgeon

Cross-referencesSee related sections for Modifiers 76 and 77 for repeated procedures and for guidance on when other modifiers (e.g., 24, 25, 58, 78) may apply