CurrentUnitedHealthcarePolicy 2025R9013A

Global Surgical Package / Global Periods for CMS 1500 billing

Defines UnitedHealthcare Medicare Advantage reimbursement rules for global surgical packages and global period assignments for services billed on the CMS 1500 form, affecting network physicians and other qualified health care professionals serving Medicare Advantage members.

Policy Summary

PayerUnitedHealthcare

PolicyGlobal Surgical Package / Global Periods for CMS 1500 billing

Policy CodePolicy 2025R9013A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate CMS 1500 claims reflecting correct codes and modifiers for Medicare Advantage members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

000,010,090Global days indicators discussed

24,25,57,58,78,79Modifiers referenced

99291/99292Critical care codes

3Global package types

Coverage and Reimbursement Criteria

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Global surgical package applies when the physician furnishes the surgery and all usual pre- and post-operative work; bill only the appropriate surgical CPT code for the procedure (no separate billing for services included in the global package).

Included Services

Pre-operative visits after decision to operate (for major procedures includes visit the day before surgery; for minor procedures includes pre-op visit the day of surgery).
Intra-operative services that are normally a usual and necessary part of the surgical procedure.
All additional medical or surgical services required of the surgeon during the post-operative period that do not require additional trips to the operating room.
Follow-up visits during the post-operative period related to recovery from the surgery.
Post-surgical pain management by the surgeon.
Supplies (except those specifically identified as exclusions).
Miscellaneous routine post-operative care such as dressing changes, incision care, removal of sutures and staples, catheter insertion/removal, routine IV lines, nasogastric/rectal tubes, tracheostomy tube changes/removal, and similar services.

Not Included (may be billed separately)

Initial consultation or evaluation resulting in the decision to perform major surgery (report modifier -57); initial evaluation for minor procedures and endoscopies is included in the global package.
Visits unrelated to the diagnosis for which the surgical procedure was performed (unless visits occur due to complications).
Services of other physicians related to the surgery, except when there is a written transfer-of-care agreement retained in the medical record documenting reassignment to another physician or group.
Treatment for the underlying condition or added courses of treatment that are not part of normal recovery from surgery.
Diagnostic tests and procedures, including diagnostic radiology, when not part of included global services.

Split/Shared and Multiple Physicians: When different physicians in the same group participate in patient care, the group practice may bill for the entire global package if benefits are reassigned to the group; payment for post-operative care may be split among physicians where transfer-of-care occurs but combined payments may not exceed what would have been paid to a single physician unless otherwise allowed. A written transfer agreement must be retained in the beneficiary's medical record. When no transfer occurs, services of another physician may be paid separately or denied based on medical necessity and circumstances.

Same-Specialty/Same-TIN Rule: A procedure with Global Days Value 000, 010 or 090 performed during the postoperative period of an earlier procedure by a physician of the same TIN and specialty is considered included in the global surgical package of the earlier procedure and is not separately reimbursable unless an appropriate modifier is appended and supported by the medical record.

Modifier Guidance (overview): Appropriate CPT modifiers are required to indicate services that are not included in the global package (for example, -57, -25, -24, -79, -78, -58) and must be supported by documentation per the policy sections describing each modifier's use.

Separate reimbursement criteria during global periods

Services or procedures performed during a global period may be considered separately reimbursable only when the specific criteria and required documentation/modifiers below are met.

Modifier -58 (Staged or Related Procedure): Modifier -58 may be reported when the subsequent procedure was planned prospectively or at the time of the original procedure, is more extensive than the original procedure, or is therapy following a diagnostic surgical procedure. When -58 is reported, a new post-operative period begins and the staged procedure may be separately reimbursable if documented.

Modifier -78 (Return to OR for Related Complication): Modifier -78 should be reported for procedures to treat postoperative complications that require a return trip to the operating room (OR defined as a place of service specifically equipped and staffed for procedures). When -78 is reported for a qualifying return to OR, pay the intra-operative portion based on the MPFS intraoperative percentage (Field 18) multiplied by the fee schedule amount (Field 34 or 35) except: (1) no -78 reduction is applied to codes with Global Days other than 010 or 090; (2) no -78 reduction is applied if the code lacks an intraoperative percentage in the MPFS; and (3) a new global period will not apply and multiple procedure reductions will not be applied.

Modifier -79 (Unrelated Procedure): Modifier -79 is used to indicate that a procedure or service furnished during the postoperative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed; such procedures may be separately reimbursable when documentation supports unrelated care.

Modifier -24 (E/M Unrelated to Surgery): Modifier -24 may be appended to an E/M service furnished during the postoperative period to indicate the E/M is unrelated to the original procedure. The E/M billed with -24 must be accompanied by documentation supporting that the service is not related to post-operative care for the procedure.

Critical Care (CPT 99291/99292): Critical care services (CPT 99291/99292) furnished during a global period may be paid separately when: the patient is critically ill and requires constant attendance of the physician; the critical care is above and beyond and generally unrelated to the surgical procedure; CPT codes 99291/99292 and modifier -FT are reported; and documentation (including an ICD-10 diagnosis indicating an unrelated condition) demonstrates the care was unrelated to the surgery.

Unspecified Procedure Codes for Return to OR: If no CPT code exists that describes the services performed during the return trip to the OR, report an appropriate unspecified procedure code in the correct series (e.g., 47999 or 64999) and append modifier -78 as applicable.

Same-TIN/Same-Specialty Inclusion Rule: Any procedure with Global Days Value 000, 010 or 090 performed during the postoperative period of an earlier procedure by a physician of the same TIN and specialty is considered included in the earlier procedure's global package and is not separately reimbursable unless an appropriate modifier (58, 78, or 79) is appended and the medical record supports it.

Coding, Modifiers, and Global Period Indicators

Global period indicatorsmixed

000	Endoscopic or minor procedure; global concept generally does not include pre/post days; day of procedure work only (no separate E/M reimbursable except as noted).
010	Minor procedure with 10-day postoperative period (no separate E/M reimbursable on day of procedure or during 10-day post-op period except as noted).
090	Major procedure with 1-day preoperative and 90-day postoperative period (total global period 92 days); E/M services on pre-op day, day of, and during 90-day post-op generally not reimbursable except as noted).
YYY	UnitedHealthcare Medicare Advantage determines whether the global concept applies and establishes the postoperative period, if appropriate, at time of pricing.
ZZZ	Code is related to another service and is always included in the Global Period of the primary service; the Global Surgical Package concept does not apply to the ZZZ code (add-on codes billed with another service).

Critical care CPT codesCPTCovered

99291	Critical care, first 30-74 minutes
99292	Each additional 30 minutes

Unspecified procedure codes for return to OR when no specific code existsCPT

47999	Unlisted procedure, abdomen (use when no specific code exists for return to OR related procedure).
64999	Unlisted procedure, nervous system (use when no specific code exists for return to OR related procedure).

Global period duration — mapping of indicators to days

000Zero-day (000): no pre-operative period and no post‑operative days; visit on day of procedure is generally not payable separately.

010Ten-day (010): no pre-operative day; day of procedure generally not payable separately; total global period = day of surgery + 10 post‑op days (11 days total).

090Ninety-day (090): includes one pre-operative day; day of procedure generally not payable separately; total global period = 1 pre-op day + day of surgery + 90 post‑op days (92 days total).

Intraoperative percentage rule for modifier -78 payment

RuleFor CPT codes billed with modifier -78 (return to OR for related procedure), payment is the fee schedule amount multiplied by the intraoperative percentage listed in MPFS Field 18 (multiply Field 34/35 amount by Field 18 percent and round to nearest cent).

Exception -000If the original code has a '000' global period, pay the full value for the procedure when billed with -78 because these codes have no pre-, post-, or intraoperative partitioned values.

Exception -no percentageIf an intraoperative percentage is not listed in the NPFS for the code, the -78 reduction based on Field 18 does not apply and payment is handled accordingly.

Provider Billing Actions and Modifier Use

Note

Claims submission and applicability — CMS 1500 claims

This reimbursement policy applies to UnitedHealthcare Medicare Advantage Plans. Submit accurate CMS 1500 claims using the codes and modifiers that correctly describe services provided. Use correct coding and documentation to support modifier use and payment.

Applicable to Medicare Advantage CMS 1500 claims
Submit accurate claims with correct codes and modifiers

Billing Rule

Use of modifiers -79 and -24

Modifier -79: Use when a procedure or service performed during the post‑operative period is unrelated to the original procedure. A new post‑operative period begins when the unrelated procedure is billed. Modifier -24: Use when an E/M service is furnished during the post‑operative period of an unrelated procedure. The E/M billed with modifier -24 must be supported by documentation showing the service is not related to postoperative care of the procedure.

Modifier -79: report when subsequent procedure is unrelated to original procedure; starts new post‑op period
Modifier -24: report with E/M during post‑op period when unrelated; include supporting documentation

Billing Rule

Use of modifier -78

Report modifier -78 when treatment of postoperative complications requires a return to the operating room (OR). The OR is a dedicated, staffed place of service (includes cath, laser, endoscopy suites; excludes patient room, minor treatment room, recovery room, or ICU unless emergency prevented transfer). Notes on payment and application: - -78 reductions apply only for procedures with Global Days Value 010 or 090 and only when an Intraoperative Percentage is present in the CMS MPFS Relative Value File. If no Intraoperative Percentage is listed (e.g., CPT code 77750), reimbursement will not be reduced even if -78 is appended. - A procedure with a '000' global period billed with -78 is paid at full value. - A new global period does not begin with -78, and multiple‑procedure reductions are not applied. Billing guidance: bill the CPT code that describes the procedure(s) performed during the return trip to the OR (use unspecified code in the correct series, e.g., 47999 or 64999, if no specific code exists). Append modifier -78 to the related procedure code.

Report -78 when returning to OR for treatment of postoperative complications
-78 reductions apply only for Global Days 010 or 090 and when an intraoperative percentage exists
CPT codes with 000 global period billed with -78 receive full payment
Do not start a new global period when -78 is reported

Billing Rule

Use of modifier -58

Modifier -58 indicates a staged or related procedure during the postoperative period that was planned prospectively, more extensive than the original procedure, or for therapy following a diagnostic surgical procedure. When -58 is reported for the staged procedure, a new postoperative period begins when that subsequent procedure is billed.

Use -58 for planned staged procedures, procedures more extensive than the original, or therapeutic procedures following a diagnostic surgery
A new post‑operative period begins when the next staged procedure is billed

Documentation Required

Critical care during global period

Critical care (CPT 99291/99292) provided during a global surgical period may be paid separately when the care is for a critically ill or injured patient and is above and beyond, and generally unrelated to, the specific anatomic injury or surgical procedure. Requirements for separate payment: - Use CPT codes 99291/99292 with modifier -FT; and - Submit documentation (including an ICD‑10 code for a separate disease or injury when appropriate) demonstrating the critical care was unrelated to the surgery and that the patient required constant physician attendance.

Critical care must be for a critically ill patient and unrelated to the surgical procedure
Report 99291/99292 with modifier -FT
Provide documentation or an ICD‑10 code showing critical care was unrelated to the surgery

Definitions and Key Terms

Global Surgical Package (Global Surgery) — definition

DefinitionThe Global Surgical Package (Global Surgery) is the set of services normally furnished by a surgeon before, during, and after a procedure that are included in the reimbursement for that procedure; modifiers should be used to indicate services not part of the package.

IncludesVisits after decision to operate (beginning the day before for major procedures, day of for others), intra‑operative services, postoperative follow‑up related to recovery, post‑procedure pain management, applicable supplies, and routine postoperative care (dressing changes, suture removal, catheter management).

Policy alignmentUnitedHealthcare Medicare Advantage follows CMS/NPFS definitions and global days value assignments in administering Global Surgical Packages.

ZZZ indicator — explanation and inclusion in global period

ZZZ indicator meaning'ZZZ' codes are add‑on surgical codes that are always billed with a primary service; there is no post‑operative work included in NPFS payment for ZZZ codes and the global period applies to the primary code.

Billing implicationPayment is made for both the primary and the add‑on code, but the add‑on has no separate postoperative work allocation in NPFS.

Relation to Global DaysZZZ is recognized as a distinct indicator from 000/010/090 and is treated as an add‑on always reported with a primary service.

Global Surgical Package — alternate/related definition

Alternate definitionGlobal Surgical Package: the bundle of preoperative, intraoperative, and postoperative services included in payment for a procedure as defined by CMS; used interchangeably with 'Global Surgery'.

Components listedIncludes pre‑op visits, intraoperative services, postoperative visits related to recovery, management of post‑op pain, supplies (except exclusions), and routine postoperative care items and services.

Group practice rulePhysicians in the same group practice and same specialty must bill and be paid as though they were a single physician for global package services.

Intraoperative Percentage — definition and use

DefinitionIntraoperative Percentage is the percentage of the Global Surgical Package assigned to the intraoperative portion of a procedure (listed in MPFS Field 18) used to compute payment when modifier -78 is reported.

Calculation useMultiply the procedure fee schedule amount (Field 34 or 35) by the intraoperative percentage (Field 18) to determine payment for a -78 return‑to‑OR service; round to nearest cent.

When not usedIf the code has a '000' global period or lacks an intraoperative percentage in the NPFS, the intraoperative‑percentage adjustment for -78 is not applied and full value may be paid for return‑to‑OR cases as applicable.

Same Specialty / Same Individual — definition of billing/payment rules

Same SpecialtySame Specialty Physician or other health care professional: physicians/qualified health care professionals of the same group and same specialty reporting the same Federal Tax Identification number; they are treated as a single physician for billing and payment of global package services.

Same IndividualSame Individual refers to the same clinician reporting the same National Provider Identifier (NPI).

Payment implicationWhen follow‑up care is furnished by another provider in the same group and specialty under the same TIN, UnitedHealthcare will not separately reimburse an additional E/M for services included in the global package (per CMS rules).