Policy No: 101
Date of Origin: 11/01/2008
Last Reviewed: 07/01/2020
Last Revised: 07/01/2020
This policy applies only to physicians and other qualified health care professionals
A period of time starting with the pre-operative period of a surgical procedure and ending some period of time after the procedure was performed.
Centers for Medicare & Medicaid (CMS) global surgery indicators are found in the CMS National Physician Fee Schedule Relative Value Files.
000 - Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.
010 - Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable.
090 - Major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule amount.
MMM - Maternity codes; usual global period does not apply.
XXX - The global concept does not apply to the code.
YYY - The carrier is to determine whether the global concept applies and establishes postoperative period, if appropriate, at time of pricing.
ZZZ - The code is related to another service and is always included in the global period of the other service.
Preoperative Evaluation and Management (E&M) Denial
E&M codes when provided on the day of or the day before a surgical procedure which has a 90 day global period.
Same Day E&M Denial
E&M codes when provided on the same day as a procedure or service with:
- A CMS assigned global period of 0, 10, 90 or XXX days.
A global period established by our health plan for codes for which CMS has not established a global period and has not indicated that a global period is inappropriate, e.g. codes with a CMS status indicator of C – Carrier priced codes
Postoperative E&M Denial
E&M codes when provided during the global period of the surgical procedure.
Surgical procedures with a 1-day preoperative period and 90 day postoperative period.
Surgical procedures with a 0 or 10 day postoperative period.
Our health plan follows the CMS published global period as documented in the current year CMS National Physician Fee Schedule Relative Value File. Our health plan reserves the right to establish a global period for codes for which CMS has not established a global period but has not indicated that a global period is inappropriate, i.e. codes with a CMS global period indicator MMM or specialty society coding recommendations such as American College of Obstetricians and Gynecologists guidelines.
Unlisted codes and/or codes with no CMS established relative value may be assigned the same global period as the most closely comparable CPT code for which an allowance is determined.
When multiple procedures are performed at the same operative session, the procedure with the longer global period will take precedence.
Components of a Global Surgical Package
Reimbursement for surgical procedures includes payment for all related services and supplies that are necessary and/or related to that procedure. Appending a modifier will not bypass these denials. These components of the surgical package are not eligible for separate reimbursement when provided within the global period. This applies to services performed in all places of services including, but not limited to, physician office, hospital, ASC, etc.
Providers within the same provider group with the same or similar specialty are subject to the same global period rules when covering for another provider.
The reimbursement for a surgical procedure includes payment for all E&M services that are related to that procedure:
- A minor procedure includes the day of surgery unless that E&M service was for a significant, unrelated and separately identifiable E&M service than the surgical procedure performed. In this case, the E&M code may be eligible for separate reimbursement if modifier 25 is appended to the E&M code.
A major procedure includes the day before and the day of surgery unless that E&M service resulted in the initial decision to perform that surgical procedure. In this case, the E&M code may be eligible for separate reimbursement if modifier 57 is appended to the E&M code
EXCEPTIONS to major procedure requirement:
- Anesthesia codes: Preoperative denials will apply to anesthesia services.
Global maternity package codes: Preoperative denials will apply 270 days prior to delivery (refer to Reimbursement Policy Med 107, Maternity Care).
The reimbursement for a surgical procedure includes payment for all intraoperative services that are a normal, usual and necessary part of that surgical procedure.
This includes but is not limited to:
- Cleansing, shaving and prepping of skin
- Draping and positioning of patient
- Insertion of intravenous access for medication administration
- Insertion of urinary catheter
- Sedative administration by the physician performing a procedure
- Local, topical or regional anesthesia administered by the physician performing the procedure
- Surgical approach including identification of anatomical landmarks, incision, evaluation of the surgical field, debridement of traumatized tissue, lysis of adhesions, and isolation of structures limiting access to the surgical field such as bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring
- Surgical cultures
- Wound irrigation
- Insertion and removal of drains, suction devices, and pumps into same site
- Surgical closure and dressings
- Application, management, and removal of postoperative dressings and analgesic devices (peri-incisional)
- Application of TENS unit
- Institution of Patient Controlled Anesthesia
- Preoperative, intraoperative and postoperative documentation, including photographs, drawings, dictation, or transcription as necessary to document the services provided
Surgical supplies, except for specific situations where CMS policy permits separate payment
The reimbursement for a surgical procedure includes payment for all professional services that are related to that procedure and are provided during the postoperative period.
This includes but is not limited to:
- Dressing changes.
- E&M services related to the original surgery, all settings (including home postpartum visits)
- Incisional care
- Postoperative pain management by the surgeon
- Removal of staples, tubes, drains, lines, wires, casts, splints and cutaneous sutures
- Postoperative care or treatment (including complications) that are related to the original surgery but do not require a return trip to the operating room
- Insertion, irrigation and removal of catheters
- Removal of operative pack
- Removal of peripheral intravenous lines
- Removal of nasogastric and rectal tubes
Changes and removal of tracheostomy tubes
EXCEPTIONS to Postoperative follow-up days:
- Anesthesia codes: Postoperative denials will apply to anesthesia codes one day after the anesthetic was provided.
Global maternity package codes: Postoperative denials will apply to global maternity delivery codes up to 45 days after delivery
A procedure or service performed within the global period solely to confirm the success or to exclude a complication of the initial procedure is not eligible for separate reimbursement.
The reimbursement for a surgical procedure with '0' postoperative days as assigned by CMS, includes a global period of the first 24 postoperative hours.
If an E&M service is provided during the global period of a surgical procedure that is unrelated to that surgical procedure, the E&M code may be eligible for separate reimbursement if modifier 24 is appended to the E&M code.
Preoperative, Same Day and Postoperative denials are applied in ClaimsXten™. More information about ClaimsXten editing can be found in the ClaimsXten Editing and the ClaimsXten Rules sections of our Coding Toolkit.
Treatment of surgical complications that are related to never events (as defined in Reimbursement Policy Adm 106 - Preventable Adverse Events) are not eligible for separate reimbursement regardless of modifier used.
Services Not Included in the Global Surgical Package
Some professional services are not included in the reimbursement for a surgical procedure and therefore may be eligible for separate reimbursement. It may be necessary to append an appropriate modifier to the code for the service to identify the circumstances which make the code eligible for separate reimbursement. These services include but are not limited to:
- Evaluation of the problem by the surgeon to determine the need for surgery
- An E&M service the day before or the day of a major surgical procedure only if the initial decision to perform the surgery was made during that visit. Modifier 57 must be appended to the E&M code to indicate decision for surgery.
- An E&M service provided on the same day as a minor procedure only if the E&M service is unrelated to the procedure performed. Modifier 25 must be appended to the E&M code to indicate the E&M is significant and separately identifiable.
- An E&M service during the surgical postoperative period only if the visit is unrelated to the surgical procedure. Modifier 24 must be attached to the E&M code to indicate the E&M is unrelated to the procedure performed.
- A repeat surgical procedure by the same surgeon performed on the same day as the original surgery, requiring a return trip to the operating room. Modifier 76 must be attached to the procedure code to indicate a repeat surgical procedure
- A repeat surgical procedure by a different surgeon, on the same day as the original surgery, requiring a return trip to the operating room. Modifier 77 must be attached to the procedure code to indicate a repeat surgical procedure by a different surgeon.
- A procedure or treatment that is related to the original surgery that requires an unplanned return to the operating room. Modifier 78 must be attached to the surgical code to indicate unplanned return to the OR.
- A procedure or service that is unrelated to the original surgery. Modifier 79 must be attached to the procedure code to indicate the surgery is unrelated to the original procedure.
A staged surgical procedure (one that was planned at the time of the original surgery) performed during the postoperative period of the original surgery. Modifier 58 must be attached to the procedure code to indicate a staged procedure.
Separate reimbursement for E&M services will not be allowed for non-surgical services (e.g., Chemotherapy Administration) that already include payment for the E&M service. If the E&M service is documented to be unrelated and separately identifiable, modifier 25 appended to the E&M code may allow separate reimbursement for the E&M service.
Procedure codes with a CMS "XXX" global period have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed, therefore separate reimbursement for E&M service will not be made. However, if the E&M service was for a significantly and separately identifiable service modifier 25 should be appended to the E&M code for reimbursement consideration.
Reimbursement for medical procedures (i.e., Chiropractic and Osteopathic Manipulative Treatment, Acupuncture) includes payment for all related supplies that are necessary and/or related to that procedure. Appending a modifier will not bypass these denials.
One or More Sessions Codes
Codes in CPT with descriptors that include the phrase 'one or more sessions' are eligible for reimbursement only once within their own global period, regardless of the number of sessions necessary to complete the treatment and regardless of the modifier attached.
American Medical Association. Appendix A: Modifiers. Current Procedural Terminology (CPT). Current year version
CMS National Physician Fee Schedule Relative Value File
Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners