CurrentUnitedHealthcarePolicy N/A

Global Surgical Package / Global Periods reimbursement

Defines UnitedHealthcare Community Plan's reimbursement rules for services included in or excluded from the Global Surgical Package, global day assignments, modifier handling (including modifier 78), and applicability to providers billing Medicaid products on CMS-1500/UB-04 forms.

Policy Summary

PayerUnitedHealthcare

PolicyGlobal Surgical Package / Global Periods reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using codes that correctly describe services and append appropriate modifiers to indicate services not part of the global package.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

84%Modifier 78 intraop reimbursement

60dNC specific global day for S0280/S0281

000/010/090Global Days categories referenced

3Common global period lengths described

CMS NPFSPrimary external reference

Related Billing Codes

CPT-59510-GLOBAL-CESAREAN-DELIVERY

CPT 59510: Global Cesarean Delivery Care

CPT-59410-GLOBAL-VAGINAL-DELIVERY-WITH-POSTPARTUM-CARE

CPT 59410: Global Vaginal Delivery with Postpartum Care

CPT-59430-POSTPARTUM-FOLLOW-UP-OUTPATIENT-CARE

CPT 59430: Postpartum Follow-Up Care, Outpatient

CPT-59400-GLOBAL-VAGINAL-DELIVERY-OBSTETRIC-CARE

CPT 59400: Global Obstetric Care for Full-Term Vaginal Delivery

CPT-59515-CESAREAN-DELIVERY-GLOBAL-SERVICE

CPT 59515: Cesarean Delivery, Global Service

HCPCS-S0281-MEDICAL-HOME-CARE-COORDINATION-PLAN-MAINTENANCE

HCPCS Level II S0281: Medical Home Care Coordination and Plan Maintenance

HCPCS-S0280-MEDICAL-HOME-INITIAL-CARE-PLANNING

HCPCS Level II S0280: Medical Home Initial Care Coordination

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Global Surgical Package Coverage Criteria

Global Surgical Package coverage criteria

Covered when ALL of the following rules are met; certain services and circumstances are not included in the Global Surgical Package and may be separately reimbursable as noted.

ALL of the following

ALL of the following
- Preoperative visits: not separately reimbursable when performed within the assigned Global Period; begins the day before surgery for Major Procedures (Global Days Value = 090) and the day of surgery for other Global Days Values.
  See global period definitions for 000/010/090 behavior.
- Complications following a procedure that do not require return to the operating room: included when occurring within the designated Global Period.
- Postoperative visits related to recovery following surgery: included when within the designated Global Period.
- Post-procedure pain management by the Same Specialty Physician or Other Qualified Health Care Professional: included.
- Selected supplies and miscellaneous routine services related to the procedure (dressing changes; incision care; removal of sutures, staples, lines, drains; catheter insertion/removal; routine IV lines; tracheostomy care, etc.): included.
- A procedure with Global Days Value 000, 010 or 090 performed during the postoperative period of another procedure with Global Days Value 010 or 090 by the Same Specialty Physician/Other Qualified HCP is considered included in the initial procedure's global package unless an appropriate modifier is appended.
  Modifiers 58, 78, 79 may identify exceptions.

ALL of the following

Services of a physician who is not the Same Specialty Physician or Other Qualified Health Care Professional: not included.
Initial consultation/evaluation for Major Procedures when reported with modifier 57: separately reimbursable for Major Procedures (Global Days Value = 090); initial evaluation for procedures with other Global Days Values is included in the procedure allowance.
Visits that are unrelated to the diagnosis for which the procedure was performed: append modifier 25 for same-day E/M and modifier 24 during the postoperative period for separate reimbursement.
Critical care services unrelated to the specific anatomic injury or general surgical procedure: may be paid separately when documentation shows the patient meets the definition of critical care; append modifier FT.
Diagnostic tests and procedures (including lab and x-rays): not included.

ALL of the following

Modifier 25: A significant, separately identifiable E/M on the same day of a procedure requires modifier 25 on the E/M code; separate diagnosis codes are not required for reimbursement of such E/M services.
Modifier 24: Unrelated E/M during the postoperative period is reimbursable with modifier 24 appended.
Modifier 78: For procedures with Global Days Value 010 or 090 that have an intraoperative percentage in the CMS PFS, UnitedHealthcare reimburses the intraoperative percentage at 84% of the Allowable Amount; modifier 78 reductions do not apply to codes without an intraoperative percentage or to procedures with Global Days Values other than 010/090. A new global period will not be established and multiple procedure reductions will not be applied when modifier 78 reimbursement rules are invoked.
Reimbursement reduction percent = 84% of Allowable Amount.
Modifiers 58 and 79: may be used to report staged/related procedures (58) or distinct non-reoperation procedures (79) during the postoperative period to indicate separate reimbursement when appropriate.
Modifier FT: append when critical care services are unrelated to the procedure to indicate separate reimbursement.

ALL of the following

Global Days Value 000: global period begins and ends on same day as procedure; E/M services on that day only are generally included.
Global Days Value 010 (and 042 where applicable): includes E/M services on day of procedure and during the 10 (or 42) days following the procedure, beginning the first day after the procedure.
Global Days Value 090: includes E/M services on the day before, the day of, and during the 90 days following the procedure.
When a procedure with Global Days Value 010 or 090 is performed and during its postoperative period another procedure with Global Days Value 000/010/090 is performed by the same TIN and specialty, the subsequent procedure is considered included in the original global package unless an appropriate modifier is reported (58, 78 or 79).

ALL of the following

North Carolina exception: HCPCS codes S0280 and S0281 have a global day period of 60 days when billed with CPT codes 59400, 59410, 59430, 59510, or 59515 per state requirement.

Code-Specific Rules and Modifiers

HCPCS codes with North Carolina state exceptionHCPCS

S0280	HCPCS state-exception code referenced for NC global day adjustment
S0281	HCPCS state-exception code referenced for NC global day adjustment

Modifier 78 — Intraoperative Reimbursement Reduction

Modifier78

ApplicabilityApplies when modifier 78 is reported for a procedure with a Global Days Value of 010 or 090 that has an Intraoperative Percentage in the CMS PFS Relative Value File.

Reimbursement actionUnitedHealthcare Community Plan reimburses the Intraoperative Percentage of the modified procedure at 84% of the Allowable Amount.

ExceptionsNo modifier 78 reduction is applied to procedures without an Intraoperative Percentage in the CMS PFS or to procedures with Global Days other than 010 or 090.

Other effectsA new global period will not be established and multiple procedure reductions will not be applied when modifier 78 reimbursement reduction is used.

Claims Submission and Modifier Use (Provider Actions)

Billing Rule

Submit accurate claims and use appropriate modifiers on CMS‑1500/UB‑04

You are responsible for submission of accurate claims using the codes that correctly describe the services provided; submit services on the appropriate CMS-1500 (or electronic equivalent) or UB-04 form as applicable and append applicable modifiers to indicate services not included in the global surgical package.

Use CPT, CMS or other coding guidelines referenced by UnitedHealthcare Community Plan to select the code(s) that accurately describe the service.
Report services on the CMS-1500 form (or electronic equivalent) or UB-04 when specified.
Append the appropriate modifier (for example: 24, 25, 57, 58, 78, 79, FT) to indicate services that are separate from the global surgical package or otherwise affect reimbursement.

Key Definitions

Global Surgical Package — Definition

DefinitionThe Global Surgical Package is the set of services before, during, and after a procedure that are included in the procedure reimbursement, including preoperative visits (when applicable), postoperative visits, management of complications not requiring return to the OR, post‑procedure pain management, certain supplies, and miscellaneous routine services.

Included timeframesFor Major Procedures, visits beginning the day before the procedure; for other procedures, visits beginning the day of the procedure; postoperative period as assigned by the Global Days Value (e.g., 000, 010, 090).

Included service examplesPostoperative visits, post‑procedure pain management, dressing changes, removal of sutures/staples, insertion/removal of urinary catheters and routine IV lines (unless specifically excluded).

Same Specialty Physician or Other Qualified Health Care Professional — Definition

DefinitionPhysicians and/or other qualified health care professionals of the same group and same specialty reporting the same Federal Tax Identification Number (TIN).