Global surgery periods: 0, 10 and 90 day billing rules

What is a global surgery period?

A global surgery period is the span of days around a surgical procedure for which Medicare's single fee already pays the surgeon's related care. Under the national global surgery policy, the fee for most procedures covers the surgery plus related visits before and after it, so those visits are not billed on their own.

42 CFR 414.40(b)(1) lists global surgery policy among the uniform national policies CMS sets for the fee schedule. Chapter 12, section 40 of the Claims Processing Manual says the national definition keeps every MAC paying the same services the same way, and that it applies to surgeries performed on or after January 1, 1992. It applies in any setting, including hospitals, surgical centers and offices, and a surgeon's visits in intensive or critical care are part of the package.

Providers in the same group with the same specialty must bill and accept payment as if they were one physician.

How long is a 0, 10 or 90 day global period?

The code's global indicator on the Medicare Physician Fee Schedule sets the length. Use the fee schedule look-up tool, select Global under Modifier, and read the indicator for each code, as the MLN907166 booklet describes.

The manual's own example for a major procedure is surgery on January 5, a pre-op day of January 4 and a last post-op day of April 5.

What is included in the global surgical package?

Section 40.1 of the Claims Processing Manual lists what the surgeon's fee covers and what stays billable.

For this rule an operating room is a place equipped and staffed solely for procedures. It includes a cardiac catheterization suite, a laser suite and an endoscopy suite. It excludes a patient's room, a minor treatment room, a recovery room and an intensive care unit.

When can I bill an E/M during a global period?

Bill it when a modifier shows the visit is outside the package, and only then. Manual section 40.4 says E/M services billed on the same day or in the post-op period without modifier 24, 25, 57 or FT are denied, and visits billed with 24 or FT without enough documentation are denied too.

The six global surgery modifiers are also among the modifiers that can get past an NCCI edit. The manual says CCI edits run first and global surgery edits run on the correctly coded services.

How is split global care billed with modifiers 54, 55 and 56?

When two providers share a package after a transfer of care, each bills the same surgery code and date of service with a different modifier. Modifier 54 means surgical care only, 55 means post-operative management only and 56 means pre-operative care only, per the MLN booklet. Split billing does not apply to 000 codes.

• Both bills carry the date of surgery as the date of service. The date care was relinquished or assumed goes in item 19 of the CMS-1500 or the remarks field of the 837P.
• Both providers keep the written transfer agreement in the patient's record.
• The provider taking over cannot bill any part of the package until he or she has seen the patient once.
• If the surgery and the follow-up happen in different payment localities, each bill goes to the MAC for that locality.

Medicare pays each provider the share shown in fields 17 to 19 of the fee schedule database and splits the post-op share by days of responsibility.

How do global surgery edits show up on the remit?

MACs run prepayment edits that look for services inside the global period billed by the same provider or group without modifier 24, 25, 57, 78 or 79. Services billed with 25, 57, 58, 78 or 79 are excluded from that audit and can be paid separately when the other requirements are met.

X12 defines reason code 97 as a benefit included in the payment for another service already adjudicated. When fragmented charges exceed the global fee, the MAC pays no more than the global amount. If a later claim reveals package services already paid, the MAC adjusts the new claim by the amount paid or starts the overpayment process.

How do ER physicians and facilities fit into a global package?

Mostly they sit outside it. The package belongs to the surgeon and the surgeon's same-group, same-specialty colleagues, while the Policy Manual says Global Surgery Rules do not apply to hospitals.

For professional ED claims, the manual excludes emergency department E/M codes 99281 to 99285 from the global prepayment edits. When an ED physician repairs or treats a minor problem, that physician bills the procedure without a modifier, and a physician who later does the minor follow-up bills an office visit code without a modifier. The emergency medicine billing page covers the facility side.

Other physicians' services stay billable unless they and the surgeon agreed on a transfer of care. A surgeon's own visit that decides on major surgery takes modifier 57.

What are the post-operative reporting and appeal rules?

Practitioners in certain practices must also report post-op visits with CPT code 99024. The MLN booklet applies this to practitioners in a group of 10 or more in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon or Rhode Island who bill one of the required procedure codes.

To contest a global denial, file a redetermination within 120 calendar days of receipt, with receipt presumed 5 days after the notice date, under 42 CFR 405.942. Attach a note and diagnosis showing a 24 or 79 service was unrelated, or the operative report for a 78. See Medicare appeal levels for later stages.

If this rule is costing you claims, our denial management team can help, and our medical coding team checks modifiers before submission.