What is the Global Period in Medical Billing

The health care industry serves thousands of Medicare patients regularly. Some
of these patients are treated using non-surgical procedures while others are
required to undergo surgical procedures depending on the severity of the illness.
The patients who are required to undergo surgery are likely to stay in the
hospital for a few days considering the intensity of the procedure and the time of
recovery. In such cases, the payment is made based on the global period.
However, one cannot comprehend the global period and its role in medical billing
without understanding the term global surgery as they both are interlinked.

Definition of Global Surgery (or Global Surgical Package)

The Centers for Medicare & Medicaid Services (CMS) defines Global Surgery as a
field that “provides the postoperative time frames that apply to payment for each
surgical procedure or another indicator that describes the applicability of the
global concept to the service”.

Based on the phrase ‘time frames’ in the definition of Global Surgery, we may
define the global period as a time that begins with a surgical procedure and ends
a few days after the surgical procedure. So, in simple words, the global period
covers the length of a patient’s hospital stay during postoperative care.

Phases of Global Surgery

In the Global Surgery is divided into three phases:
 Preoperative evaluation
 Intraoperative procedure
 Postoperative care

The Postoperative Care (Global Period)

As mentioned earlier the global period covers a patient’s stay in hospital
postoperative. Based on the coverage of the post-operative time frame the global
period is divided into three phases—zero-days, ten days, and ninety days.

At present, the values used by CMS as global surgery indicators given in the CMS
National Physician Fee Schedule Relative Value Files are—000, 010, 090, MMM,
XXX, YYY, and ZZZ as given in the document
https://www.cms.gov/apps/physician-fee-schedule/help/How_to_MPFS_Booklet_IC
N901344.pdf
 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 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; evaluation
and management 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 the 90-day postoperative period included in
the fee schedule payment amount.”
 MMM: “Maternity codes; usual global period does not apply.”
 XXX: “Global concept does not apply.”
 YYY: “MAC determines whether global concept applies and establishes postoperative period, if
appropriate, at time of pricing.”
 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.)”
The medical biller is trained to generate a bill for the global surgical package
using appropriate surgical codes and modifiers. This ensures maximum
reimbursement for the global period by eliminating any delay in payments.

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
• Treatment for post-operative complications requiring a return trip to the Operating Room (OR). An OR,
for this purpose, 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, or an intensive care
unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an
OR).
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is
payable separately.
• Immunosuppressive therapy for organ transplants
• Critical care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured
or burned patient is critically ill and requires constant attendance of the physician.
What Is Global Period In Medical Billing?
Medical billing specialists are required to understand and comply with the
rules and terms associated with billing various insurances and Medicare. One
of the terms that we may run into in billing is what’s called a “global period”
in medical billing.
This term refers to the period of time that begins up to 24 hours before a
surgical procedure starts. It ends at a period of time after the procedure has
ended. That period varies based on the nature of the procedure.
Depending on what type of surgery is performed, there may be a follow-up
period during which follow-up care is included in the payment for the
procedure, and not separately payable. That care is considered “bundled” into
the global surgery fee.
Important Must-Knows About Global Period In
Medical Billing
 The global periods adopted by the Centers for Medicare & Medicaid
Services are typically followed by other payers as well.
 Surgery reimbursement includes payment for all related services and
supplies that are routine and needed for the procedure.
 A global surgery service can be completed in any setting, including
hospitals, doctor’s offices, or an ambulatory surgery center.
Medicare payment for procedures includes a variety of services, such as:
 Pre-op services for minor or major procedures (one day before major
surgery and the day of, for minor surgery)
 Intraoperative services that are a necessary part of the surgery
 Post-operative services, including items such as dressing changes or
incision care, post-op pain management, removal of sutures, and more
 Supplies used that are required for and related to the surgery

Services that are not included in a global surgical package include services
like consultations, other doctor’s services, treatment for underlying conditions,
diagnostic tests that are outside of the surgical procedure, and more.
To ensure that all the proper services are billed to Medicare, it requires careful
monitoring of the global fee periods. Understanding and using the codes
correctly will help reduce inappropriate billing, denials or an interruption in
medical services for the patient.
Coding for Surgical Procedures in the
Global Period
In order to understand Medicare coding for surgery performed during the global
period of another surgery, the concepts of the global fee, the global period, and
the correlating Medicare definitions of major surgery and minor surgery should be
mastered. Although the Centers for Medicare and Medicaid Services (CMS) has
published a Proposed Rule for 2015 that would eliminate the global period
starting with minor procedures in 2017 and major procedures in 2018, that
proposal has not been implemented, and it remains to be seen if any of these
proposed guidelines will become final rules.

THE GLOBAL FEE

The global fee is the amount of money Medicare approves as payment for a
given surgical procedure. It is composed of 3 distinct time periods: (1)
preoperative visits after the decision is made to operate, beginning with the day
before the day of surgery for major procedures and the day of surgery for minor
procedures; (2) intraoperative services that are essentially the surgical
procedure(s) itself; (3) postoperative services, which include all additional related
medical or surgical services the surgeon provides due to complications that do
not require additional trips to the OR during the postoperative period.

Many physicians question why there is no compensation for preoperative office

visits for minor procedures, such as intravitreal injections, or for related problems
treated in the office during the postoperative period. The answer is that
physicians are being paid: The global fee, by definition, encompasses payment
for all 3 time periods.

THE GLOBAL PERIOD

Medicare defines the global period as that period of time during which a
physician may not bill for related office visits. The global period may be 90, 10, or
0 days. According to Medicare, a major surgery has a global period of 90 days,
and a minor surgery has a global period of either 10 or 0 days. Thus, the time
frame of, not the complexity of, the surgery determines whether a surgery is
major or minor.

SURGICAL PROCEDURES PERFORMED IN THE GLOBAL PERIOD

Surgical procedures performed in the global period of another operation may be
related or unrelated. In order for a claim for such surgeries to be paid, a modifier
must be appended on the claim (Table).

If the additional surgery to be performed during the global period is planned

prospectively, is more complex than the original operation, or is a therapeutic
surgery following a diagnostic surgery, modifier 58 should be used.

If the operation is for postoperative complications or is related to the original

surgery in any way, then modifier 78 should be appended. Modifier 78 requires
that the surgery be done in an OR, which Medicare has defined as a place of
service specifically equipped and staffed for the sole purpose of performing
procedures. These include cardiac catheterization suites, laser suites, and
endoscopy suites. It does not include patient examination rooms, minor treatment
rooms, recovery rooms, or intensive care units.

If a surgical intervention for a related problem is performed during the global

period but is performed in-office, the intervention is not reimbursable unless
performed in a suitable place of service as defined above.

If the surgery to be performed is in no way related to the original surgery,

modifier 79 should be used.

MODIFIERS
In order to be paid for a surgical procedure that is performed within the global
period of another procedure, the appropriate modifier must be applied. The
choice is among modifiers 58, 78, and 79. Complete descriptions of these
modifiers are found in the Current Procedural Terminology handbook. A brief
listing is provided in the Table. These modifiers apply to the same surgeon in the
same session.
4 Tips Help You Understand the Global Surgical Package Rules

Remember that modifier 54 must always accompany modifier 55.

Although a surgical procedure typically only lasts one day, your eye care specialist’s services may span
months after the actual surgery — and in most cases, insurers won’t reimburse separately for those follow-up
visits. Because the pre- and post-surgical care is included in the global surgical package, it’s important to
understand what the global period involves and how long it lasts.

Global periods may be irrelevant for some procedures, but they can last up to 90 days for others, said NGS
Medicare’s Nathan Kennedy during the Part B payer’s May 12 webinar, “Medicare Global Surgery Policy.”

Read on for the lessons that Kennedy shared so you can understand exactly when global periods apply, and
what the rules are.

1. Know What the Global Surgical Package Includes

“Global surgery is one of the things that we sometimes forget about, but it’s been around for 30 years now,”
Kennedy said. “The global surgery concept includes all of the necessary services by the physician or the
nonphysician practitioner before, during, and after the surgical procedure.”

The word “global” refers to the fact that the entire package encompasses everything related to the surgical
service and the recovery period, so providers get one amount rather than billing for the pre- and post-surgical
components a la carte.

The global package not only includes services provided by the surgeon during the global period, but also other
providers in the same group and specialty during that period, Kennedy added.

2. You Can Find Global Periods in the Fee Schedule

If you’re curious about the global period for a particular ophthalmologic procedure, you can check the
Medicare Physician Fee Schedule, Kennedy said. Under “global days,” you’ll see the number of days included
in the global period, with the following as a guide:

 000: This period indicates that related preoperative and postoperative care on the day of the procedure
are included in the fee for the procedure itself. Any related evaluation and management (E/M) work
done on the same day as a procedure with this global indicator is generally included. For instance,
under Medicare guidelines, 65205 (Removal of foreign body, external eye; conjunctival superficial)
has a global period of 0 days. Therefore, any related E/M procedures performed on the same day of
service are typically not separately reportable.
 010: This period indicates that Medicare includes 10 days of postoperative care in the payment of a
procedure. Any E/M services you perform on the day of the procedure and during the 10-day global
period “are generally not separately reimbursed,” Medicare guidelines indicate. As an example, code
65855 (Trabeculoplasty by laser surgery) carries 10 global days.
  090: Procedures with 90-day global periods have one day of preoperative care and 90 days of
postoperative care included in the fee for the initial procedure. For instance, code 66982
(Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure),
manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex,
requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion
device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on
patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation) has a
90-day global period.
 XXX: Codes assigned “XXX” are not subject to the global period concept. This designation is
typically seen with E/M, lab tests, and radiology tests, but may be seen with other services. Visual
fields, ophthalmic imaging, and certain other procedures found in the Medicine section of CPT® are
examples of procedures not subject to the global period concept.

Medicare lists the global periods in its fee schedule, but you should ask private payers for their global periods
and policies in writing, because they may differ from Medicare’s.

3. Some Services Are Excluded From the Global Package

“As far as services excluded from global surgery, first, and probably most important, is the initial evaluation
and determination for a major surgical procedure,” Kennedy said. Codes with a 90-day global period are
considered major surgeries. If the decision for surgery E/M service is performed on the same day, or the day
before an unscheduled surgery, you should append modifier 57 (Decision for surgery) to receive separate
payment for the E/M work, he said.

Procedures with global periods of 0 or 10 days are generally considered “minor procedures.” Because of this
designation, Medicare and private payers don’t pay separately for the exams performed on the same day. In
order to get paid for a separately identifiable and medically necessary office visit performed on the same day
as a minor procedure, you have to ensure that the documentation supports a significant, separately identifiable
visit, in which case you can append 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).

Not included in the surgical package are visits provided by physicians in different group practices or in a
different specialty in the same group. “But we still advise you that even if it’s a different physician of a
different specialty, if they’re in the same group, that you should still use the global surgery modifiers to
indicate those are different,” Kennedy advised. “Some of the editing that CMS has in place is based on tax
identification number and we’ve seen several instances where even though they are different specialties they
still get pulled into the global surgery policy and editing.”

Also not included in the surgical package are visits addressing other diagnoses, he said. “It’s possible that
physician could do surgery for one condition and then still continue to see the patient after surgery for other
conditions,” he said.
Finally, diagnostic tests are not considered part of the global package. Tests performed during the global
period are usually separately payable.

4. Global Modifiers Can Help

In some cases, you may need to use modifiers to tell your payers that you performed services during the global
period that were unrelated to the surgery. For instance, if the patient returns to the practice during the global
period for evaluation of a different problem, you can append modifier 24 (Unrelated evaluation and
management service by the same physician or other qualified health care professional during a postoperative
period) to the E/M code. “Modifier 24 tells the payer, ‘Yes, the service was rendered during this patient’s
global period, but it’s not related. It has nothing to do with that surgery,’” Kennedy said.

You should also know how to use modifiers 54 (Surgical care only) and 55 (Postoperative Management only),
Kennedy said. “This is for a split care situation. We see this also a lot in specialty areas like eye surgeries.
Many eye surgeries will be performed by an ophthalmologist, and then postoperative care would be turned
over to an optometrist,” he said.

In this case, the surgeon will bill the surgical code with modifier 54 appended to it, and the optometrist will
submit the claim using the same date as the original surgery and the original surgical code with modifier 55
appended. In the “remarks” field of the claim form, the physicians should each indicate the date they
relinquished (in the case of the surgeon) or assumed (in the case of the optometrist) care. Keep in mind that the
surgeon may also report modifier 55 if they keep the patient for a portion of the global period.