For services on or after December 17, 2007, see policy N-99.
Certain services are paid for under what are known as “global fees.” These fees incorporate the reimbursement for services performed at different times by the same provider (or group), but all in conjunction with one medical procedure or episode of care.
Indications and Limitations of Coverage
A standard package of preoperative, intraoperative and postoperative services are included in the payment for a surgical procedure.
All surgical procedures are classified as one of the following:
- major surgery
- minor surgery
Procedures identified as major surgery have a 90-day postoperative period; procedures identified as minor surgery procedures have either a 10-day postoperative period or no postoperative period; and most endoscopic surgery has no postoperative period.
To determine the global period for major surgeries, count 1 day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery. To determine the global period for minor procedures, count the day of surgery and the appropriate number of days immediately following the date of surgery.
Components of a Global Surgical Package
When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group.
The approved amount for surgical procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery:
- Preoperative Visits -- Preoperative visits beginning with the day before the date of surgery for major procedures and the day of surgery for minor procedures.
- Intraoperative Services -- Intraoperative services that are normally a usual and necessary part of the surgical procedure, including postoperative work in the hospital.
- Complications Following Surgery -- All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room.
- Postoperative Visits -- Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery.
- Post-surgical Pain Management -- By the surgeon.
- Supplies -- See exception to this under “Services not included in the Global Surgical Package.”
Miscellaneous Services -- Items such as dressing changes; local incisional care; removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
Services Not Included in the Global Surgical Packages
The following services are not included in the global surgical package and can be paid for separately in addition to the surgical procedure:
- The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.
- Modifier 57 must be reported with the E/M service if this consultation or evaluation is the day before major surgery or the day of major surgery.
- A visit on the same day as a minor or endoscopic procedure that is for a significant separately identifiable service, above and beyond care normally associated with the procedure.
- Modifier 25 must be reported with the E/M service to identify it as a significant separately identifiable service.
- Modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service.
- Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim.
- Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician 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.
- Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record or ASC record.
- Visits following the patient’s discharge that are unrelated to the diagnosis for which the surgical procedure is performed (unless due to complications of the surgery).
- Modifier 24 must be reported with the E/M service to identify it as unrelated. Additionally, sufficient documentation must show that the visit was unrelated to the surgery. A diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery is sufficient documentation.
- Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery.
- Diagnostic tests and procedures including diagnostic radiological procedures.
- Physical therapy.
- Clearly distinct surgical procedures during the postoperative period which are not reoperations or treatments for complications.
- Modifier 58 should be used to identify procedures done in 2 or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure.
- Modifier 79 must be reported to identify unrelated procedures performed during the post-operative period.
- Treatment for postoperative complications which require a return trip to the operating room. An operating room for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures, including a cardiac catheterization suite, a laser suite and an endoscopy suite. It does not include a patients room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR).
- Modifier 78 must be reported with the subsequent surgical procedure.
- If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
- Modifier 58 must be reported with the second procedure.
- Major surgery performed on the same day or in the postoperative period of a diagnostic biopsy with a 10-day global period is separately payable.
- A surgical tray (A4550) is not separately reimbursable because it is considered a bundled service. Therefore, it is noncovered and nonbillable to the member.
- Splints and casting supplies for fractures or dislocations may be reimbursed when performed in a physician’s office (codes A4649, L0210, Q4001-Q4051).
- Recastings during the global period of the treatment of a fracture.
- Modifier 58 (staged procedure) or Modifier 79 (unrelated procedure) should be reported with the recasting code.
- Immunosuppressive therapy for organ transplants
- Modifier 24 should be reported to identify the care (even if it is during the same hospital stay as the surgical procedure). It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.
- Critical care services (code 99291) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
- Modifier 25 must be reported with code 99291 if rendered in the pre-operative period and modifier 24 for post-operative care.
- Documentation that the critical care was unrelated to the specific anatomic injury or surgical procedure must be submitted. A diagnosis code in the range of 800.0-929.9 or 940.0-959.9 which clearly indicates that the critical care was unrelated to the surgery is acceptable documentation.
MCM 4820 - 4822
CMS Online Manual Pub. 100-04, Chapter 12, Section 30/30.6.6
Transmittal 954, CR 5025