The Global Surgical Package & Separate Physician Payment for Follow-Up Care

When it comes to Medicare’s global surgical package, confusion reigns. This article offers guidance on documentation related to site of service. 

Editor’s Note: Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure information accuracy. However, HMP Communications and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying information accuracy lies with the reader.    

There seems to be confusion about Medicare’s global surgical package and separate physician payment for follow-up care among those who attend seminars taught by this author. The first issue to clarify is that the Medicare global surgical package does not apply to hospital-based outpatient departments (HOPDs) that are paid by the Medicare Ambulatory Payment Classification system. The global surgical package only pertains to physicians who are paid via the Medicare Physician Fee Schedule. To better understand the global surgical package, let’s take a look at the guidance provided in Chapter 12 of the Medicare Claims Processing Manual.¹ NOTE: The Medicare examples in this article have been modified to reflect those services applicable to wound care.

Components of a Global Surgical Package  

The Medicare Part A and Part B (A/B) Medicare Administrative Contractors (MACs) apply the national definition of a global surgical package to all procedures. The services included in the global surgical package may be furnished in any setting (eg, hospitals, HOPDs, ambulatory surgical centers [ASCs], physicians’ offices.) The Medicare-approved allowable rates for these procedures include payment for the following services related to the surgery when furnished by the physician who performs the surgery: 

• Preoperative Visits: Preoperative visits after the decision is made to operate, beginning with the day before the day of surgery for major procedures (90-day global periods) and the day of surgery for minor procedures (0-day and 10-day global periods).
• Intraoperative Services: Intraoperative services that are normally a usual and necessary part of a surgical procedure. 
• Complications Following Surgery: All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room (OR).
• Postoperative Visits: Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery.
• Postsurgical Pain Management: By the surgeon.
• Supplies: Except for those identified as exclusions.
• Miscellaneous Services: Items such as dressing changes; local incisional care; removal of operative pack; and removal of cutaneous sutures, staples, lines, wires, tubes, drains, casts, and splints.

Services Not Included in the Global Surgical Package 

The A/B MACs do not include the services listed below in the payment amount for a procedure. Therefore, these services may be paid for separately.

• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. NOTE: This policy only applies to major surgical procedures that have a 90-day global period. The initial evaluation is always included in the allowance for a minor (0-day or 10-day) surgical procedure. REMINDER: Most wound care procedures performed in an HOPD or physician/other qualified healthcare professional’s (QHP’s) office have a 0-day global period. Examples include surgical debridements, application of cellular and/or tissue-based products for skin wounds, negative pressure wound therapy (both durable medical equipment and disposable), selective debridement, and nonselective debridement.
• 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. An example of this is the transfer of care for postoperative care of an inpatient to a wound care physician in the HOPD. 
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery. For example, the discovery of a new ulcer on the opposite foot.
• Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery. For example, the treatment of uncontrolled diabetes after a surgical debridement in the OR
• Diagnostic tests and procedures, including diagnostic radiological procedures. 
• Clearly distinct surgical procedures during the postoperative period that are not re-operations or treatment for complications. (A new postoperative period begins with the subsequent procedure.) This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. For example, a staged wound closure on a large burn.   
• Treatment for postoperative complications that requires a return trip to the OR. For this purpose, an OR is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term 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, an intensive care unit (unless the patient’s condition is so critical that there is not sufficient time for transportation to an OR), or an HOPD.
• If a less extensive procedure fails and a more extensive procedure is required, the second procedure is separately payable. For instance, if a wound does not heal properly after a surgical debridement is performed and a wide excision of the wound is necessary, the wide excision is considered a more extensive procedure.
• Splints and casting supplies provided in a physician’s/other QHP’s office are payable separately under the reasonable charge payment methodology. NOTE: This does not apply to HOPDs. 

Physicians Furnishing Less Than Full Global Package 

There are occasions when more than one physician provides services included in the global surgical package. For example, when the physician who performs the surgical procedure chooses not to furnish the required follow-up care. Payment for the postoperative, post-discharge care is split between the surgeon who agrees to the transfer of care and the physician/QHP who agrees to accept the transfer of care. As stated previously, this transfer of care agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record. An example of this might be the transfer of an inpatient for postoperative wound care to a physician in an HOPD. NOTE: When more than one physician furnishes services that are included in the global surgical package, the sum of the Medicare payment to all involved physicians may not exceed the Medicare allowable amount that would have been paid if a single physician provided all the global surgical services. In other words, the total Medicare global surgical allowable rate for each Current Procedural Terminology (CPT^®) code cannot be exceeded because the surgeon decided not to perform all the service required during the global surgical period. If a transfer of care does not occur and the second physician bills for care during the global surgical period, the second physician’s claim may either be paid separately or denied for medical-necessity reasons, depending on the circumstances of the case.  

Determining Duration of Global Surgical Period  

For major surgeries assigned a 90-day global surgical package, the A/B MACs count one day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery.
EXAMPLE: Preoperative period: Jan. 4; Date of surgery: Jan. 5; Last date of postoperative period: April 5. For minor surgeries assigned a 10-day global surgical package, the A/B MACs count the day of surgery and the 10 days immediately following the date of surgery. EXAMPLE: Date of surgery: Jan. 5; Last day of postoperative period: Jan. 15. For minor surgeries assigned a 0-day global surgical package, all services provided that day are included in the payment for the procedure. REMINDER: Most wound care procedures performed in the HOPD or in the physician’s office are assigned a 0-day global period.

Billing Requirements

To ensure the proper identification of services that are/are not included in the global surgical package, the following procedures apply: (NOTE: Use of the modifiers discussed applies to both major procedures with a 90-day postoperative period and minor procedures with a 10-day postoperative period, and/or a 0-day postoperative period in the case of modifiers “-22” and “-25.”) 

Physicians Who Furnish Entire Global Surgical Package 

Physicians who perform the surgery and furnish all of the usual pre-and postoperative work should bill for the entire global surgical package by entering the appropriate CPT code for the surgical procedure. Additional billing is not allowed for visits or other services that are included in the global surgical package.   

Physicians in Group Practice 

When different physicians in a group practice participate in the care of the patient, the group should bill for the entire global surgical package if the physicians reassign benefits to the group. The physician who performs the surgery is shown as the “performing physician.” 

Physicians Who Furnish Part of a Global Surgical Package 

When physicians agree on transfer of care during the global surgical period, both of their claims will contain the same date of service and the same surgical procedure code. The services will be distinguished by the use of the appropriate modifiers: 

• The surgeon should add Modifier “-54,” surgical care only, to his/her CPT code.
• The physician providing the postoperative care should add Modifier “-55,” postoperative management only, to the same CPT code at the first postoperative visit.

The claims do not have to specify that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim in the “Remarks” field/free-text segment. 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. NOTE: When a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global surgical services until he/she actually provides 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. This is particularly important when a physician in an HOPD or in an office setting assumes the postoperative care for a surgeon. In order for the physician in the HOPD or office to bill for the postoperative care, there must be an official transfer of care documented in the medical record. Exceptions: 

• When 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 (E&M) code. No modifiers are necessary on the claim. 
• If the transfer of care occurs immediately after surgery, the receiving physician who provides in-hospital postoperative care bills using subsequent hospital care codes for the inpatient hospital care and the surgical code with Modifier “-55” for the post-discharge care. The surgeon bills the surgery code with Modifier “-54.” 
• If one physician performs a minor procedure in the emergency department, that physician should bill for the surgical procedure without a modifier. If another physician provides follow-up care for the minor procedure, that physician should bill the appropriate level of office visit code. 
• 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 should report the appropriate E&M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.

E&M Services Resulting in Initial Decision to Perform Surgery

E&M 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 E&M code, Modifier “-57,” decision for surgery, is used to identify a visit that results in the initial decision to perform surgery. NOTE: E&M services that occur on the day of surgery should not be billed with Modifier “-25.” Modifier “-57” should not be used with minor surgical procedures because the global surgical period for minor surgeries does not include the day prior to the surgery. Because the decision to perform the minor surgical procedure typically occurs immediately before the procedure, it is considered a routine preoperative service and an E&M visit or consultation should not be billed in addition to the procedure. NOTE: Physicians should not bill an E&M service on the same day as when a minor surgery is performed. This rule applies to the many wound care procedures assigned 0-day global surgical periods that are performed in the physician/QHP office or in the HOPD.

Return Trips to the OR During the Postoperative Period 

When treatment for complications requires a return trip to the OR, physicians should 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 (eg, 47999 or 64999). NOTE: The procedure code for the original surgery should not be used, except when the identical procedure is repeated. Physicians should append the CPT Modifier “-78,” unplanned return to the operating/procedure room by the same physician or other QHP following initial procedure for a related procedure during the postoperative period, to the appropriate CPT code for these return trips. If the physician needs to perform multiple procedures in the OR during the postoperative period of the initial procedure and the subsequent procedure is related to the first procedure, this circumstance is also reported by adding Modifier “-78” to the related procedure. NOTE: The CPT definition for Modifier “-78” does not limit its use to treatment for complications.

Unrelated Procedures or Visits During Postoperative Period

Two CPT modifiers were established to simplify billing for visits and other procedures that are furnished during the postoperative period of a surgical procedure but are not included in the payment for the surgical procedure:

1. Modifier “-24,” unrelated E&M service by the same physician or other QHP during a postoperative period, should be used to indicate that an E&M service for an unrelated problem was performed during the postoperative period. This circumstance is reported by adding Modifier “-24” to the appropriate level of the E&M service. NOTE: Services submitted with Modifier “-24” should 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. NOTE: A physician who is responsible for postoperative care and has reported and been paid using Modifier “-55” should also use Modifier “-24” to report any unrelated visits.
2. Modifier “-79,” unrelated procedure or service by the same physician or other QHP during the postoperative period, should be used to indicate that the performance of a procedure or service during a postoperative period was unrelated to the original procedures. A new postoperative period begins when the unrelated procedure is billed. 

Significant E&M, Day of Procedure

Modifier “-25,” significant, separately identifiable E&M service by the same physician or other QHP on the same day of the procedure or other service, is used 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 E&M service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. This circumstance should be reported by adding Modifier “-25” to the appropriate level of E&M service. NOTE: The physician needs to emphasize how the E&M service is above and beyond the usual E&M service that is included in the procedure.

Unusual Circumstances

Surgeries for which services performed are significantly greater than usually required may be billed with Modifier “-22,” increased procedural services, added to the CPT code for the procedure. 

NOTE: Modifier “-22” should only be reported with procedure codes that have a global period of 0, 10, or 90 days. Surgeries for which services performed are significantly less than usually required may be billed with Modifier “-52,” reduced services. NOTE: Modifier “-52” is not restricted and may be used with any service/procedure that is reduced. When modifiers are used to report these unusual circumstances, the claims should include a concise statement that describes how the service differs from the usual and an operative report. 

Reporting Correct Date(s) During Global Surgical Period

Surgeons 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 on the claim. This will enable A/B MACs to relate all appropriate billings to the correct surgery. Surgeons who share postoperative management with another physician must submit the date they relinquished responsibility for the postoperative care on their claim. Physicians who assume the postoperative care must submit the date they assumed the postoperative care on their claim.

• If the physician who performed the surgery relinquishes care at the time of discharge, he/she should only show the date of surgery when billing with Modifier “-54.”
• If the surgeon also cares for the patient for some period following discharge, the surgeon should show on his/her claim the date of surgery and the date on which the postoperative care was relinquished to another physician. The physician providing the remaining postoperative care must show on his/her claim the date care was assumed. This information should be shown in Item 19 on the paper Form CMS-1500, which is the same form locator on the electronic record.

Conclusion

This article should remind physicians who assume postoperative work from a surgeon of the billing rules associated with their claim submissions.  Obviously, documentation plays a large role in proper billing. Especially highlighted are the rules surrounding transfer of care and use of modifiers “-54” and “-55,” as well as appropriate use of modifiers “-22,” “-24,” “-25,” “-52,” “-57,” “-78,” and “-79.” It’s important for physicians who work in HOPDs that accept postoperative cases for treatment to develop relationships with the surgeons who transfer their patients during the global surgical period. Transfer-of-care orders and appropriate use of modifiers “-54” and “-55” are essential for the physician to obtain appropriate reimbursement for their postoperative care. 

Donna Cartwright is senior director of strategic reimbursement for Integra LifeSciences Corp., Plainsboro, NJ. She’s approved as a certified trainer on ICD-10-CM by the American Health Information Management Association and has been designated as a fellow of the American Health Information Management Association.

Reference

1. Physicians/Nonphysician Practitioners. In: Medicare Claims Processing Manual. Accessed online: www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf