Bulk Up Your Global Surgical Package Knowledge for Cleaner Claims

Medicare global surgical package rules

Let’s take Medicare’s list of services included in global surgery payment up a notch. If you remember each added tip below, you’ll be more likely to avoid reporting both too many and too few codes.

Read This Booklet to Dive Deeper

The source of the straight-from-Medicare bullet points quoted below is Medicare’s Global Surgery Booklet. As a quick refresher, the global surgical package includes required services typically furnished by a surgeon (or same-specialty physician in the same group) before, during, and after a procedure. The Medicare payment for a surgical code covers all of those typical pre-, intra-, and post-operative services. That’s why you should not report those services separately. Now, to the bullet points!

Supplement Global Package Knowledge With Top Tips

Each quoted bullet point below is listed by Medicare as included in the global surgery payment when provided in addition to the surgery.

  • “Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-operative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.”
    • Tip: For major procedures, you may bill the initial evaluation separately using modifier 57 (Decision for surgery) on the E/M code. For minor procedures, Medicare includes the initial evaluation in the global surgery package, but you may report a significant, separately identifiable E/M on the same date as the procedure by appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). A major procedure is one with a 90-day global period (one day pre-op, the day of the procedure, and 90 days following the procedure). Minor procedures may have 0-day (no pre-op or post-op days) or 10-day (the day of surgery and 10 days following) global periods.
  • “Intra-operative services that are normally a usual and necessary part of a surgical procedure”
    • Tip: Don’t confuse intra-operative services with “multiple surgeries.” Intra-operative services are elements of more major surgeries. “Multiple surgeries” refers to separate procedures the physician (or one in the same group) performed on the same day for which Medicare may pay separately. Expect Medicare to apply the multiple procedure payment reduction based on Medicare Physician Fee Schedule (MPFS) rules.
  • “All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room”
    • Tip: The AMA CPT® guidelines for the Surgery section say “Complications … should be separately reported.” But Medicare specifies that a return to the operating room is required to report the service separately. You’ll append modifier 78 (Unplanned return to the operating/procedure room …) to the code for the service performed during the return trip. Operating room may have a broader definition than you’d expect because Medicare specifies in the Global Surgery Booklet that it is “a place of service specifically equipped and staffed for the sole purpose of performing procedures.” A cardiac catheterization suite, a laser suite, or an endoscopy suite counts. A minor treatment room, recovery room, or ICU does not. Although if there is not time to transport the patient to another room because the situation is so critical, Medicare may waive the rule.
  • “Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery”
    • Tip: Pay attention to the term “related to recovery.” Medicare does not consider treatment for the underlying condition to be part of normal recovery, so you may report that treatment separately.
  • “Post-surgical pain management by the surgeon”
    • Tip: The Correct Coding Initiative (CCI) manual offers some more information on this point. This quote is from Chapter 4.I.27, but you’ll find words to this effect in more than one place in the manual: “Medicare Global Surgery Rules prevent separate payment for postoperative pain management when provided by the physician performing an operative procedure. CPT® codes 36000, 36410, 62320-62327, 64400-64489, and 96360-96377 describe some services that may be utilized for postoperative pain management. The services described by these codes may be reported by the physician performing the operative procedure only if provided for purposes unrelated to the postoperative pain management, the operative procedure, or anesthesia for the procedure.”
  • “Supplies, except for those identified as exclusions”
    • Tip: CPT® Surgery section guidelines for 2019 state that you may separately report supplies “over and above those usually included with the procedure(s) rendered.” The guidelines state to use 99070 (Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) or the specific supply code. Most likely you’ll be reporting a HCPCS code that offers more detail about the supply.
  • “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 tube.”
    • Tip: Don’t let that long list of included items make you miss separately reportable services, such as diagnostic tests and procedures and clearly distinct surgical procedures that aren’t re-operations or treatment for complications. Medicare’s Global Surgery Booklet offers information on both what is and is not included in the global surgical package.

What About You?

Do you think having the global surgical package is helpful, or do you think it makes coding for surgery more confusing?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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