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 pre-operative, 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.
The following modifiers are used by physicians to indicate a billed service is not part of a global surgical package and is eligible for separate reimbursement:
Modifier and Description
24 – Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.
An excision of a malignant lesion on the left arm is performed in the office on January 10, 2009. The ICD-9-CM diagnosis code reported is 171.2. The post-operative period designated for excision code 11606 is 10 days.
The patient returns to the office on January 15, 2009 and is treated for contact dermatitis, ICD-9-CM code 692.0. The physician should report the appropriate evaluation and management code followed by the 24 modifier, e.g., 99212-24.
In order for the evaluation and management service to be payable in the post-operative period with the 24 modifier, the diagnosis code supporting the E/M service must be different from the diagnosis code reported for the previously performed surgery.
Modifier 24 should not be used for the medical management of a patient by the surgeon following surgery. Medicare recognizes modifier 24 only for the care following a discharge under these circumstances:
The care is for immunotherapy management furnished by the transplant surgeon;
The care is for critical care (99291, 99292) for a burn or trauma patient under diagnosis codes 800.0-929.9, 940.0-959.9; or
The documentation demonstrates that the visit occurred during a subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery.
25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.
Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
57 – Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.
E/M services on the day before or on the day of major surgery ( 90 day global period) which result in the initial decision to perform the surgery are not included in the global surgery payment. These E/M services may be billed separately and identified with the 57 modifier.
This modifier should not be used for visits furnished during the global period of minor procedures (0 or 10 day global period ) unless the purpose of the visit is a decision for major surgery. This modifier 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. See modifier 25.
58 – Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding the modifier 58 to the staged or related procedure.
Note: For treatment of a problem that required a return to the operating or procedure room (e.g., unanticipated clinical condition), see modifier 78.
59 – Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Modifier 59 should only be used if there is no other more descriptive modifier available and the use of modifier 59 best explains the circumstances. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25
78 – Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76).
79 – Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79. (For repeat procedures on the same day, see modifier 76).
Global Modifiers: CPT Modifiers 25 and 57
When Is It Proper to Use Both Modifiers
This billing guide is being published to assist providers who bill for multiple surgical procedures with a mixture of 0, 10 and/or 90 global days.
Situation:
A provider is billing for an evaluation and management service (E/M) performed on the same day as a major surgery and a minor surgery.
Example:
Initial hospital visit – 99223 (decision for surgery made on the same day)
Major Procedure – 33881 (90 global days)
Second Procedure – 34812 (0 global days)
Third Procedure – 36140 (global days do not apply)
The E/M service is included in the major and minor surgery unless the following requirements were met:
CPT modifier 25: The E/M service was performed on the same day as a minor surgery (000 or 010 global days) is significant and separately identifiable from the usual work associated with the surgery. Documentation in the patient’s medical record must support the use of this modifier.
CPT modifier 57: The E/M service was performed on the same day or the day before a major surgery (090 global days) by the surgeon which resulted in the decision to perform the procedure. Documentation in the patient’s medical record must support the use of this modifier.
If the criteria for CPT modifiers 25 and 57 were met the claim should be submitted as 99223-5725.
Reminders:
If a provider performs a visit in the global period of more than one surgery that has 0, 10
or 90 (and sometimes YYY) global days, the visit is included in the payment of each of the surgeries
If the provider feels the visit meets the criteria to be separately payable from one of the
surgeries, he/she must add the appropriate modifier to the visit
If he/she feels the visit should be separately payable for the additional surgeries, he/she may need to add an additional modifier to the visit
A visit in the global period of a major surgery would require a different modifier versus a visit on the same day as a minor surgery, therefore if both surgeries were performed; two modifiers would be required for the visit.
Is the global surgery payment restricted to hospital inpatient settings?
Global surgery applies in any setting, including an inpatient hospital, outpatient hospital, Ambulatory Surgical Center (ASC), and physician’s office. When a surgeon visits a patient in an intensive care or critical care unit, Medicare includes these visits in the global surgical package.
How is Global Surgery classified?
There are three types of global surgical packages based on the number of post-operative days.
0-Day Post-operative Period (endoscopies and some minor procedures).
• No pre-operative period
• No post-operative days
• Visit on day of procedure is generally not payable as a separate service
10-Day Post-operative Period (other minor procedures).
• No pre-operative period
• Visit on day of the procedure is generally not payable as a separate service.
• Total global period is 11 days. Count the day of the surgery and the 10 days immediately following the day of the surgery.
90-day Post-operative Period (major procedures)
• One day pre-operative included
• Day of the procedure is generally not payable as a separate service.
• Total global period is 92 days. Count 1 day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of surgery.
What services are included in the global surgery payment?
Medicare includes the following services 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 preoperative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
• Intra-operative services that are normally a usual and necessary part of a surgical procedure
• 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
• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
• Post-surgical pain management by the surgeon
• 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.
What services are not included in the global surgery payment?
The following services are not included in the global surgical payment. These services may be billed and paid for separately:
• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier “-57” (Decision for Surgery). This visit may be billed separately only for major surgical procedures.
• Services of other physicians related to the surgery, 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 unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery
• 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
• Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications
Billing Requirements for Global Surgeries
To ensure the proper identification of services that are, or are not, included in the global package, the following procedures apply.
A.Procedure Codes and Modifiers
Use of the modifiers in this section apply to both major procedures with a 90-day postoperative period and minor procedures with a 10-day postoperative period (and/or a zero day postoperative period in the case of modifiers “-22” and “-25”).
1.Physicians Who Furnish the Entire Global Surgical Package
Physicians who perform the surgery and furnish all of the usual pre-and postoperative work bill for the global package by entering the appropriate CPT code for the surgical procedure only. Billing is not allowed for visits or other services that are included in the global package.
2.Physicians in Group Practice
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 physician who performs the surgery is shown as the performing physician. (For dates of service prior to January 1, 1994, however, where a new physician furnishes the entire postoperative care, the group billed for the surgical care and the postoperative care as separate line items with the appropriate modifiers.)
3.Physicians Who Furnish Part of a Global Surgical Package
Where physicians agree on the transfer of care during the global period, the following modifiers are used:
*“-54” for surgical care only; or
*“-55” for postoperative management only.
Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.
Providers need not specify on the claim that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim.
This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record.
Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient.
EXCEPTIONS:
*Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management code. No modifiers are necessary on the claim.
*If the transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in-hospital postoperative care bills using subsequent hospital care codes for the inpatient hospital care and the surgical code with the “- 55” modifier for the post-discharge care. The surgeon bills the surgery code with the “-54” modifier.
*Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of office visit code. The physician who performs the emergency room service bills for the surgical procedure without a modifier.
*If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports the appropriate evaluation and management code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.
4.Evaluation and Management Service Resulting in the Initial Decision to Perform Surgery
Evaluation and management 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 and, therefore, may be billed and paid separately.
In addition to the CPT evaluation and management code, modifier “-57” (decision for surgery) is used to identify a visit which results in the initial decision to perform surgery. (Modifier “-QI” was used for dates of service prior to January 1, 1994.)
If evaluation and management services occur on the day of surgery, the physician bills using modifier “-57,” not “-25.” The “-57” modifier is not used with minor surgeries because the global period for minor surgeries does not include the day
prior to the surgery. Moreover, where 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.
5.Return Trips to the Operating Room During the Postoperative Period
When treatment for complications requires a return trip to the operating room, physicians must bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, use the unspecified procedure code in the correct series, i.e., 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.
In addition to the CPT code, physicians use CPT modifier “-78” for these return trips (return to the operating room for a related procedure during a postoperative period.)
The physician may also need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first procedure and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.
NOTE: The CPT definition for this modifier does not limit its use to treatment for complications.
6.Staged or Related Procedures
Modifier “-58” was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. This modifier is not used to report the treatment of a problem that requires a return to the operating room.
The physician may need to indicate that the performance of a procedure or service during the postoperative period was:
a.Planned prospectively or at the time of the original procedure;
b.More extensive than the original procedure; or
c.For therapy following a diagnostic surgical procedure.
These circumstances may be reported by adding modifier “-58” to the staged procedure. A new postoperative period begins when the next procedure in the series is billed.
7.Unrelated Procedures or Visits During the Postoperative Period
Two CPT modifiers were established to simplify billing for visits and other procedures which are furnished during the postoperative period of a surgical procedure, but which are not included in the payment for the surgical procedure.
Modifier “-79”: Reports an unrelated procedure by the same physician during a postoperative period. The physician may need to indicate that the performance of a procedure or service during a postoperative period was unrelated to the original procedure.
A new postoperative period begins when the unrelated procedure is billed.
Modifier “-24”: Reports an unrelated evaluation and management service by same physician during a postoperative period. The physician may need to indicate that an evaluation and management service was performed during the postoperative period of an unrelated procedure. This circumstance is reported by adding the modifier
“-24” to the appropriate level of evaluation and management service.
Services submitted with the “-24” modifier must be sufficiently documented to establish 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 acceptable documentation.
A physician who is responsible for postoperative care and has reported and been paid using modifier “-55” also uses modifier “-24” to report any unrelated visits.
8.Significant Evaluation and Management on the Day of a Procedure
Modifier “-25” is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made.
It is used to report a significant, separately identifiable evaluation and management service by same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patient’s condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. This circumstance may be reported by adding the modifier “-25” to the appropriate level of evaluation and management service.
Claims containing evaluation and management codes with modifier “-25” are not subject to prepayment review except in the following situations:
*Effective January 1, 1995, all evaluation and management services provided on the same day as inpatient dialysis are denied without review with the exception of CPT Codes 99221-9223, 99251-99255, and 99238. These codes may be billed with modifier “-25” and reviewed for possible allowance if the
evaluation and management service is unrelated to the treatment of ESRD and was not, and could not, have been provided during the dialysis treatment;
*When preoperative critical care codes are being billed for within a global surgical period; and
*When A/B MACs (B) have conducted a specific medical review process and determined, after reviewing the data, that an individual or group have high statistics in terms of the use of modifier “-25,” have done a case-by-case review of the records to verify that the use of modifier “-25” was inappropriate, and have educated the individual or group as to the proper use of this modifier.
9.Critical Care
Critical care services provided during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances.
Preoperative and postoperative critical care may be paid in addition to a global fee if:
*The patient is critically ill and requires the constant attendance of the physician; and
*The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed.
Such patients are potentially unstable or have conditions that could pose a significant threat to life or risk of prolonged impairment.
Modifier -24 (post-operative) or -25 (same day pre-operative) is used to indicate that the critical care service is unrelated to the procedure.
10.Unusual Circumstances
Surgeries for which services performed are significantly greater than usually required may be billed with the “-22” modifier added to the CPT code for the procedure. Surgeries for which services performed are significantly less than usually required may be billed with the “-52” modifier. The biller must provide:
*A concise statement about how the service differs from the usual; and
*An operative report with the claim.
Modifier “-22” should only be reported with procedure codes that have a global period of 0, 10, or 90 days. There is no such restriction on the use of modifier “-52.”
B.Date(s) of Service
Physicians, who bill for the entire global surgical package or for only a portion of the care, must enter the date on which the surgical procedure was performed in the “From/To” date of service field. This will enable A/B MACs (B) to relate all appropriate billings to the correct surgery. Physicians who share postoperative management with another physician must submit additional information showing when they assumed and relinquished responsibility for the postoperative care. If the physician who performed the surgery relinquishes care at the time of discharge, he or she need only show the date of surgery when billing with modifier “-54.”
However, if the surgeon also cares for the patient for some period following discharge, the surgeon must show the date of surgery and the date on which postoperative care was relinquished to another physician. The physician providing the remaining postoperative care must show the date care was assumed. This information should be shown in Item 19 on the paper Form CMS-1500. See the related implementation guide for where to show this information on the ASC X12 837 professional claim transaction format.
C.Care Provided in Different Payment Localities
If portions of the global period are provided in different payment localities, the services should be billed to the A/B MAC (B) servicing each applicable payment locality. For example, if the surgery is performed in one state and the postoperative care is provided in another state, the surgery is billed with modifier “-54” to the A/B MAC (B) servicing the payment locality where the surgery was performed and the postoperative care is billed with modifier “-55” to the A/B MAC (B) servicing the payment locality where the postoperative care was performed. This is true whether the services were performed by the same physician/group or different physicians/groups.
D.Health Professional Shortage Area (HPSA) Payments for Services Which are Subject to the Global Surgery Rules
HPSA bonus payments may be made for global surgeries when the services are provided in HPSAs. The following are guidelines for the appropriate billing procedures:
*If the entire global package is provided in a HPSA, physicians should bill for the appropriate global surgical code with the applicable HPSA modifier.
*If only a portion of the global package is provided in a HPSA, the physician should bill using a HPSA modifier for the portion which is provided in the HPSA.
EXAMPLE
The surgical portion of the global service is provided in a non-HPSA and the postoperative portion is provided in a HPSA. The surgical portion should be billed with
the “-54” modifier and no HPSA modifier. The postoperative portion should be billed with the “-55” modifier and the appropriate HPSA modifier. The 10 percent bonus will be paid on the appropriate postoperative portion only. If a claim is submitted with a global surgical code and a HPSA modifier, the A/B MAC (B) assumes that the entire global service was provided in a HPSA in the absence of evidence otherwise.
NOTE: The sum of the payments made for the surgical and postoperative services provided in different localities will not equal the global amount in either of the localities because of geographic adjustments made through the Geographic Practice Cost Indices.
Modifier 24: Unrelated E/M Service by the Same Physician During a Postoperative Period
Applicable Providers
• Physicians, all specialties
• Multi-specialty clinics
• Podiatrists
• CRNA
• Optometrists
• Chiropractor
• Independent Lab
• Planned Parenthood
• Nurse Practitioner
• Nurse Midwives
• Portable X-Ray
General Information
Modifier 24 indicates that certain Evaluation and Management (E/M) services performed during the postoperative period of a major or minor surgery by the same provider who performed the procedure or by the provider responsible for the postoperative care of the patient are unrelated to the original procedure performed. This must be supported by a diagnosis that is unrelated to the original procedure. The postoperative period begins the day following surgery.
Policy Evaluation and management codes are normally considered part of the global package. If appended with modifier 24, Medicaid will reimburse an unrelated E/M service rendered during the postoperative period of a major or minor procedure to the same provider that performed the original procedure or to the provider responsible for postoperative care. Appending modifier 24 denotes that the service was unrelated to the original surgery. In addition, a diagnosis unrelated to the original surgery must be billed as the primary diagnosis. Medicaid will not require medical records be submitted with the claim to support the diagnosis, however, there must be evidence in the medical record to substantiate the unrelated condition.
Separate reimbursement will be allowed without appending modifier 24 if an unrelated E/M service is rendered during the postoperative period by a different provider with a different specialty than the provider that performed the original procedure. Separate reimbursement will also be allowed without appending modifier 24 if a service related to the original surgery but not part of the postoperative services is rendered by a different provider with a different specialty than the provider that performed the original procedure. An example of this is a consultation with a radiologist or oncologist to determine the course of treatment following surgery.
Even though modifier 24 is defined as an unrelated E/M service by the same provider, Medicaid is allowing modifier 24 to be used by different providers with the same specialty as the surgeon if that provider renders an E/M service for an unrelated diagnosis during the postoperative period. Failure to bill modifier 24 and the unrelated diagnosis will result in denial. Following this procedure allows providers to avoid receiving a denial and the necessity of requesting an adjustment for reimbursement for unrelated procedures. Medicaid does not include critical care, prolonged services, emergency care services, neonatal intensive care services, nursing facility services, or home services in its global postoperative package. These E/M services can be reimbursed separately if billed within the postoperative period. Appending modifier 24 is accepted but not required.
Billing
• The surgeon and the provider rendering postoperative management of the patient must bill for unrelated E/M services rendered within the postoperative period with modifier 24 and a diagnosis that is unrelated to the original procedure.
• Appending modifier 24 to an E/M code to denote an unrelated procedure must be supported by a diagnosis code that clearly identifies the reason why it is unrelated to the original procedure. Using modifier 24 alone will not support reimbursement, but modifier 24 plus an unrelated diagnosis will.
• The diagnosis code that best describes the patient’s diagnosis, condition, problem or other reason for the visit or encounter must be placed as the first diagnosis occurrence. Codes for other diagnoses, such as chronic conditions, may be billed as secondary or additional diagnoses. Refer to the March, 1999 Medicaid Bulletin for diagnosis coding guidelines.
• When billing for a new admission within the postoperative period, the same billing rules apply. If the admission E/M service is unrelated to the original procedure, the service must be billed with modifier 24 appended to the E/M code and a diagnosis code proving the service is unrelated must be billed as the primary diagnosis. If the new admission is due to a complication of the original procedure, it is considered related and will not be reimbursed separately.
• Global periods are defined for major and minor procedures:
Major procedures:
1 day preoperative period
1 day of surgery
+90 days following surgery*
92 days total global period
Minor procedures:
1 day of surgery
+10 days following surgery
11 days total global period
*Obstetrical codes are assigned 60 days following surgery.
Coding Guidelines
• Modifier 24 can be appended to evaluation and management codes (range 99201 – 99499)and health screening (code W8001) to denote the service is unrelated.
• For a list of major and minor procedure codes, refer to the April, 1999 Medicaid Bulletin.
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