CurrentUCarePolicy N/A

Global Surgical Package (Global Surgery)

Defines Medicare's national global surgical package billing and payment rules for pre-, intra-, and post-operative services and who is affected (surgeons and other providers billing Medicare).

Policy Summary

PayerUCare

PolicyGlobal Surgical Package (Global Surgery)

Policy CodePolicy N/A

Change TypeNo substantive changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen providers transfer surgical care, report the same CPT code and use modifiers 54/55/56 as appropriate and keep a written transfer agreement in the medical record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3global period types

92major procedure total days

1110-day procedure total days

00-day procedures

Global Surgery Coverage

Global Surgery Coverage Criteria

ALL of the following

Pre-operative visits after the decision to operate (for major procedures includes the day before surgery; for minor procedures includes visits on the day of surgery).
Intra-operative services that are a necessary part of the surgical procedure.
Post-operative services provided by the surgeon for complications that do not require return to the operating room (OR).
Follow-up post-operative recovery visits and post-surgical pain management.
Supplies (except items specifically excluded).
Miscellaneous routine services such as dressing changes; local incision care; removal of operative packs, cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion/irrigation/removal of urinary catheters and routine peripheral IV lines; nasogastric and rectal tubes; and tracheostomy tube changes and removals.

ALL of the following

Surgeon’s first evaluation that results in the decision to perform major surgery (bill separately with modifier 57; applicable only to major procedures).
Services unrelated to the surgical diagnosis (unless for surgery-related complications).
Diagnostic tests and procedures (including diagnostic radiology).
Distinct surgical procedures performed during the post-operative period that are not re-operations or treatment of complications (a new post-operative period starts after such a procedure).
Treatment for post-operative complications that require return to the OR (these are separately payable).
If a less extensive procedure fails and a more extensive procedure is required, the subsequent more extensive procedure is paid separately.

ALL of the following

Procedures with 10-day global period (indicator 010): no separate payment for post-operative visits or services related to recovery within 10 days of surgery. If a diagnostic biopsy with a 10-day global period precedes a major surgery the same day or within 10 days, the major surgery is paid separately.
Procedures with 0-day global period (indicator 000): post-operative visits beyond the day of the procedure are not included in the surgery payment and may be billed and paid separately.
Split-global / transfer of care rules do not apply to 0-day codes; minor procedure services by other providers generally are not included in the global fee.

ALL of the following

When providers agree to transfer components of the global package, use modifiers 54 (surgical care only), 55 (post-operative management only), and 56 (pre-operative care only) as appropriate. The providers must report the same CPT procedure code and surgery date; keep a written transfer agreement in the medical record (letter or annotation in discharge/hospital/ASC record).
The accepting provider reporting post-operative care must perform at least one service before billing. Joint payments between providers cannot exceed the single-provider global amount and group practice billing rules apply when benefits are reassigned to the group.

ALL of the following

Use modifier 57 to report the first E/M that results in the decision for major surgery (not allowed for minor surgeries).
Use modifier 25 to report a significant, separately identifiable E/M on the same day as a minor procedure to bill that E/M separately.
When no formal transfer of care occurs: Occasional post-discharge services by other providers should be billed as E/M without transfer modifiers; use add-on HCPCS G0559 when applicable for post-operative care by a practitioner other than the surgeon or not in the same group.

ALL of the following

Document any transfer-of-care agreement by letter or annotation in the discharge summary, hospital record, or ASC record to support use of split-global modifiers.
For modifier 55 billing, the accepting provider must perform at least one service before billing for post-operative management.

ALL of the following

A provider who performs the entire global package should bill only the surgical CPT and not bill separately for services included in the global package. When benefits are reassigned to a group, group practice billing rules apply.

Global Periods & Indicators

Global Surgery Indicatorsmixed

000	Global surgery indicator for endoscopies/some minor procedures (0-day post-op)
010	Global surgery indicator for other minor procedures (10-day post-op)
090	Global surgery indicator for major procedures (90-day post-op)
YYY/ZZZ/XXX	Contractor-priced (YYY), add-on (ZZZ), or not applicable (XXX) global indicators as noted for specific CPT/HCPCS codes

Global period lengths

Global period options0, 10, or 90 post-operative days depending on procedure/global indicator

0-day period (endoscopies & some minor procedures)No pre-operative period; no post-operative days; procedure-day visits generally not payable separately

10-day period (other minor procedures)No pre-operative period; procedure day generally not separately payable; total global period = 11 days (surgery day + 10 days)

90-day period (major procedures)Includes 1 day pre-operative, day of surgery not separately payable generally; total global period = 92 days (1 pre-op + day of surgery + 90 post-op)

Billing Actions & Modifiers

Billing Rule

Transfer of Care and Modifiers

When providers agree on a transfer of care during a global surgical period, use the appropriate modifiers to distinguish which portion of the global package each provider performed and keep a written transfer agreement in the patient record (letter or annotated discharge/ASC/hospital record). Use the same global surgery CPT code and the date of service equal to the date of the surgical procedure on both the surgical and post‑operative care bill. The joint payments to multiple providers for parts of the global package may not exceed the single‑provider global amount unless otherwise allowed.

Surgical care only — modifier 54 (not for assistant‑at‑surgery services or ASC facility fees).
Post‑operative management only — modifier 55 (use with 10‑ or 90‑day global period codes; the accepting provider must provide at least one service before billing; not for assistant‑at‑surgery services or ASC facility fees).
Pre‑operative care only — modifier 56.

Billing Rule

Exceptions to Modifiers / G0559

If a formal transfer of care does not occur, do not use modifiers 54/55/56. Occasional post‑discharge services by providers other than the surgeon should be reported with the appropriate E/M code without modifiers. Use HCPCS add‑on code G0559 for post‑operative follow‑up visits provided by a practitioner who did not perform the surgical procedure (or another practitioner in the same group) to reflect additional time and resources. Minor ED follow‑up services should be billed as the level E/M code without modifiers. When another provider manages an underlying condition or complication during the post‑operative period, report the appropriate E/M code without modifiers.

Report E/M codes without modifiers for occasional post‑discharge visits by non‑surgeons when no transfer of care occurred.
Use G0559 (add‑on) to capture post‑operative follow‑up resources when provided by a practitioner other than the surgeon (or different practitioner in same group).
Do not use modifier 57 for minor surgeries; modifier 57 identifies the first E/M resulting in the decision for major surgery (see below).
Keep documentation supporting whether a transfer of care occurred (transfer agreement) and clinical notes showing the nature of post‑operative services.

Billing Rule

Decision for Surgery and Separate E/M Billing

The first E/M visit that results in the decision to perform major surgery may be billed separately using modifier 57 (Decision for Surgery). Modifier 57 applies to major surgeries and identifies the E/M service on the day of or the day before the procedure as separate from the global surgical package. Do not use modifier 57 for minor surgery decisions; those are considered routine pre‑operative services and are included in the global payment for minor procedures. MACs may deny E/M services billed with modifier 57 when provided on the day of or day before procedures with 0‑ or 10‑day global periods.

Use modifier 57 only for the first E/M that results in the decision for major surgery.
Do not apply modifier 57 to minor surgeries or to visits that are routine pre‑operative care for minor procedures.
Be aware of payer adjudication differences — MACs may not pay modifier 57 for services on the day of or day before procedures with 0‑ or 10‑day global periods.

Key Definitions & Modifiers

Global surgical package (global surgery)

DefinitionThe global surgical package (global surgery) includes all necessary services normally provided by a provider (or members of the same group with the same specialty) before, during, and after a procedure.

PurposeEstablishes a national uniform payment policy so MACs consistently pay the same services across jurisdictions.

Scope of included servicesCovers pre-operative visits after the decision to operate, intra-operative services, and post-operative visits occurring within the applicable global period (typically 10 or 90 days).

Group billingProviders in the same group practice and specialty must bill and accept payment as though they are a single physician for the global package.

Modifiers 54 / 55 / 56

Modifier 54Surgical care only — used when the surgeon provides only part of the global package (including transfer of care); does not apply to assistant-at-surgery services or ASC facility fees.

Modifier 55Post-operative management only — used by the provider accepting post-operative care for global periods of 10 or 90 days; accepting provider must perform at least one service before billing and keep a written transfer agreement in the medical record.

Modifier 56Pre-operative care only — used to indicate the surgeon provided only the pre-operative portion when care is split among providers.

Modifier 57

Modifier 57 (Decision for surgery)Identifies the first E/M visit that results in the decision to perform major surgery and may be billed separately for major procedures (not for minor surgeries); use the CPT E/M code with modifier 57.

Limitations for minor surgeriesDo not use modifier 57 with minor surgeries; visits on the day of or day before procedures with 0- or 10-day global periods may not be paid when billed with modifier 57.

Coverage noteE/M services that result in the first decision to do major surgery are not included in the global surgery payment on the day before or day of major surgery and may be billed separately.