Global Surgery and Billing Guidelines

The global surgical package, also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the preoperative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.

  • Physicians Furnishing the Entire Global Package

Physicians who furnish the surgery and furnish all of the usual pre-and post-operative care may bill for the global package by entering the appropriate CPT code for the surgical procedure only. Separate billing is not allowed for visits or other services that are included in the global package. When different physicians in a group practice participate in the care of the patient, the group practice bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is reported as the performing physician.

  • Physicians Furnishing Part of a Global Surgical Package

More than one physician may furnish services included in the global surgical package. It is possible that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the postoperative, post-discharge care is split among two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services, except where stated policies allow for a higher payment. For instance, when the surgeon furnishes only the surgery and a physician other than the surgeon furnishes pre-operative and post-operative inpatient care, the resulting combined payment may not exceed the global allowed amount. The surgeon and the physician furnishing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case. Split global-care billing does not apply to procedure codes with a 0-day postoperative period.

  • Pre-operative Period Billing

E/M services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery. Therefore, these services may be billed and paid separately. In addition to the CPT E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service, and a visit or consultation is not billed in addition to the procedure. MACs may not pay for an E/M service billed with the CPT modifier “-57” if it was provided on the day of or the day before, a procedure with a 000- or 010-day global surgical period.

  • Day of Procedure Billing

Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other services. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim. The Modifier “-25” (Significant, separately identifiable E/M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service.

  • Use modifier “-25” with the appropriate level of E/M service.
  • Use modifiers “-24” (Unrelated E/M service by the same physician during a postoperative period) and “-25” when a significant, separately identifiable E/M service on the day of a procedure falls within the postoperative period of another unrelated procedure.
  • Pre-operative Period Billing

Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for the surgical procedure.

  • Modifier “-79” (Unrelated procedure or service by the same physician during a postoperative period). The physician may need to indicate that a procedure or service furnished during a postoperative period was unrelated to the original procedure. A new postoperative period begins when the unrelated procedure is billed.
  • Modifier “-24” (Unrelated E/M service by the same physician during a postoperative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure.

Reference: Global Surgery Booklet