Global Surgical Package

Policy ID: NDRP-SURG-009

Section: Surgery

Effective Date: July 01, 2018

Revision Effective Date: December 01, 2024

Last Reviewed: September 24, 2024

Applies To: Commercial and Medicaid Expansion

Description

This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement for global surgical package and subsequent services provided within the global surgery days.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Policy

The global surgical package, also referred to as global surgery, includes all services performed by the surgeon, or by another physician or other qualified health care professional (QHP) within the same group and/or same specialty and sub-specialty, routinely performed during the pre-operative, intra-operative, and post-operative period. BCBSND classifies surgery as either major or diagnostic/minor procedures. As defined by the Centers for Medicare & Medicaid Services (CMS) the services listed below are included in the reimbursement for the global surgical package.

Global Surgery Package

Preoperative (Before Surgery)

Preoperative visits after the decision is made to operate
For major procedures, this includes preoperative visits the day before the day of surgery. For minor procedures, this includes preoperative visits the day of surgery.

Intraoperative (During Surgery)

Intraoperative services that are a normal and necessary part of the surgical procedure

Post-Operative (After Surgery)

All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications, provided they do not require additional trips to the operating room
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

Other Included Services

All services that appear in the Musculoskeletal System section of the CPT manual include the application and removal of the first cast, splint, or traction device, when performed. Subsequent replacement of cast, splint, or strapping and/or traction device during or after the global period may be reported separately with the appropriate modifier.
Supplies, except for those identified as exclusions
Miscellaneous services, such as dressing changes, local incision 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

Global Period

A global period is a period of time starting with a surgical procedure and ending some period of time after the procedure. Procedure codes that have a global period are developed based on CMS Physician Fee Schedule (PFS) Relative Value Unit (RVU) File status indicators.

Global Days Indicators

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 (E/M) services on the same 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; E/M services on the day of the procedure and during this 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 payment amount.

XXX

Global concept doesn’t apply.

YYY

Carrier is to determine whether the global concept applies and establishes postoperative period, if appropriate, at time of pricing.

Note: BCBSND assigns a 90-day global period to codes with a “YYY” global surgical indicator.

ZZZ

Code related to another service and is always included in the global period of the other service. (Note: Physician work is associated with intra-service time and in some instances the post service time.)

Note: BCBSND does not assign global days to a “ZZZ” global surgical indicator.

Split Surgical Package

A split surgical package occurs when the preoperative and/or postoperative care is rendered by another physician or QHP than the surgeon that performed the surgical service. In accordance with National Correct Coding Initiative (NCCI) Guidelines, it is required that the same surgical procedure code (with the appropriate modifier) be used by each physician/QHP to identify the service(s) provided when the components of a global surgical package are performed by a different physician or QHP.

Reimbursement for Split Surgical Package

Reimbursement for split surgical services will not exceed 100% of the total global surgical allowable amount and are reimbursable at the percentages indicated below.

Split Surgical Package Modifiers & Reimbursement Percentage

Surgical Care Only

70% of the fee schedule

Postoperative Management Only

20% of the fee schedule

Preoperative Management Only

10% of the fee schedule

Preoperative Period

An E/M visit rendered during the preoperative period is included in the global surgery allowance for the surgery and not separately reimbursable. Refer to NDRP-GC-034 Evaluation and Management Policy for more E/M policy information.

Intraoperative Period

Reduced & Discontinued Services

Reduced Services

In situations where the physician or other QHP has elected to partially reduce or eliminate the procedure the modifier 52 is appended to the procedure code, signifying that the physician did not perform the complete procedure in the code descriptor.

Discontinued Services

Professional Claims
Discontinuation of a procedure is usually the result of extenuating circumstances or those that threaten the well-being of the patient. When the surgeon elects to terminate a surgical or diagnostic procedure due to extenuating circumstances or those that threaten the well-being of the patient modifier 53 is appended.

Note: Modifier 53 may only be billed on the CMS-1500 Claim Form.

Outpatient Hospital & Ambulatory Surgical Center (ASC)
In the instance where a planned service or procedure in the hospital outpatient setting is reduced, cancelled, or discontinued and anesthesia is planned but not administered, modifier 73 would be appended to the procedure code; and if anesthesia is administered then append modifier 74.

Note: Modifiers 73 and 74 may only be billed on the UB-04 Claim Form.

Discontinued Procedure Prior to Anesthesia
A physician or other QHP may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general).

Discontinued Procedure After Administered Anesthesia
A physician or other QHP cancels the procedure due to extenuating circumstance or those that threaten the well-being of the patient after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.).

Note: Do not report modifiers 73 or 74 when a radiology procedure does not require anesthesia or the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient.

Reimbursement for Reduced & Discontinued Services

Under Enhanced Ambulatory Patient Groups (EAPGs) pricing methodology, modifier 52 or 73 can also be used on the UB-04 Claim Form to indicate a discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia.

Reduced & Discontinued Services Modifiers, Reimbursement Percentage & Claim Form

Reduced Services

50% of the fee schedule

CMS-1500 & UB-04

Discontinued Procedure

50% of the fee schedule

CMS-1500

Discontinued Outpatient Hospital/ASC Procedure Prior to the Administration of Anesthesia

50% of the fee schedule

CMS-1500 & UB-04

Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia

100% of the fee schedule

UB-04

Repeat Procedure

The sole fact that a procedure or service must be repeated after the original does not warrant additional reimbursement above the allowance for the original procedure or service being reported. Modifiers 76 (repeat procedure or service by the same physician or other QHP) or 77 (repeat procedure or service by another physician or other QHP) should be used to report the exact procedure(s) were repeated on the same date of service for the same patient. Please see our Modifiers 76, 77 & 91 (Repeat and Duplicate Services) guideline for further information regarding these modifiers.

Note: Do not append modifiers 76 or 77 to an E/M services.

Postoperative Period

According to CMS, modifier 58 (Staged or related procedure or service by the same physician during the post-operative period) was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. Modifier 58 indicates that the performance of a procedure or service during the postoperative period was:

Planned prospectively or at the time of the original procedure
More extensive than the original procedure
For therapy following a diagnostic surgical procedure

Note: A new postoperative period begins when the next procedure in the series is billed.

Unplanned Return

Modifier 78 should be reported with procedure codes for treatment of postoperative complications that require a return trip to the operating room. An operating room is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term operating room includes a cardiac catheterization suite, a laser suite and an endoscopy suite. It does not include a patient's 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 operating room).

Note: A new Global Period will not apply to a procedure meeting these requirements and reported with modifier 78. Reimbursement will be 75% of the fee schedule.

Limitations & Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross References

History

Date

Updates

10/4/2021

This policy is a combination of the reimbursement policies below. Leaving the effective date of 7/1/2018 due to no change of intent.

Global Services & Subsequent Services
Modifiers 54, 55 & 56
Modifiers 52, 53, 73 & 74
Repeat Surgical Procedures

12/14/2021

Added FT modifier information under Postoperative Period (Unrelated Services) section.

1/5/2022

Added initial and subsequent cast, splint, strapping, and traction services information.

1/24/2022

Corrected cross referenced policy name from Modifiers 25, 59, XE, XP, XS & XU

11/21/2022

Replaced all instances of “specialty” with “specialty and sub-specialty”

11/16/2023

Policy annual review completed

2/14/2024

Annual review completed. Added legal disclaimer “All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.”, added link to new Modifiers 76, 77 and 91 (Repeat and Duplicate Services) in Repeat Procedure and Cross References sections, changed “Revised Date:” to “Revision Effective Date:” and changed “separately reimbursed” to “reviewed for separate reimbursement.” under the Decision for Surgery section.

9/24/2024

Removed Decision for Surgery and unrelated services from this policy as this information is now combined in NDRP-GC-034 Evaluation and Management Policy. Created reference with Preoperative Period to NDRP-GC-034 Evaluation and Management Policy. Added reference to NDRP-GC-034 Evaluation and Management Policy.

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.

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Medical Policies Quick Search

Global Surgical Package

Contents:

Description

Policy Application

Policy

Global Surgery Package

Global Period

Global Days Indicators

Split Surgical Package

Split Surgical Package Modifiers & Reimbursement Percentage

Preoperative Period

Intraoperative Period

Reduced & Discontinued Services

Reduced Services

Discontinued Services

Reimbursement for Reduced & Discontinued Services

Reduced & Discontinued Services Modifiers, Reimbursement Percentage & Claim Form

Repeat Procedure

Postoperative Period

Unplanned Return

Limitations & Exclusions

Cross References

History

Disclaimer

Medical Policies Quick Search

Global Surgical Package

Contents:

Description

Policy Application

Policy

Global Surgery Package

Global Period

Global Days Indicators

Split Surgical Package

Split Surgical Package Modifiers & Reimbursement Percentage

Preoperative Period

Intraoperative Period

Reduced & Discontinued Services

Reduced Services

Discontinued Services

Reimbursement for Reduced & Discontinued Services

Reduced & Discontinued Services Modifiers, Reimbursement Percentage & Claim Form

Repeat Procedure

Postoperative Period

Staged or Related Procedure

Unplanned Return

Limitations & Exclusions

Cross References

History

Disclaimer