Global Surgery

Description

Reimbursement for surgical procedures includes payment for all related services and supplies that are routine and necessary for performing the procedure and recovery.

Centers for Medicare and Medicaid Services (CMS) defines the global surgical package as all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the preoperative, 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. Claims for services considered to be directly related to pre-procedure, intra-procedure, and post-procedure work are included in the global reimbursement and will not be paid separately.

The pre- and post-operative global days are based on CMS standards. The global period is defined as the period of time during which claims for related services will be denied as an unbundled component of the total surgical package. Major procedures have a global period of 90 days. Minor procedures have a global period of 10 or 0 days. The global period includes, but is not limited to, Evaluation and Management services that are related to the procedure. 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. Therefore, these services may be billed and paid separately

Claims may be processed according to same group practice or same provider ID. Same group practice is defined as a physician and/or other qualified health care professional of the same group and same specialty with the same Federal Tax ID number.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse services or supplies billed during the global period according to the criteria outlined in this policy.

Services or supplies Blue Cross NC considers to be mutually exclusive, incidental to, integral to, or within the global period of the primary service rendered are not eligible for reimbursement.

Reimbursement Guidelines

Blue Cross NC follows the Centers for Medicare and Medicaid Services (CMS) guidance in regard to services included in and excluded from the Global Surgical Package.

Procedures billed in an office setting during a global period for the same procedure will be understood to represent postoperative care and be reimbursed as such.

Blue Cross NC may review modifiers used during global periods for appropriate usage.

Non-physician practitioners (NPP) are only eligible for reimbursement of a Major Procedure (90 day) when submitted with an assistant modifier.

Modifier Use During the Global Period Days:

• Modifier 24 signifies an unrelated Evaluation and Management (E/M) service during a postoperative period. Documentation must support the use of this modifier in the global period in order for a service to be eligible for reimbursement.
• Modifier 25 represents a significant and separately identifiable E&M service on the same day of a procedure or other service. Documentation must support the use of this modifier and provide the necessary detail in order for a service to be eligible for reimbursement.
• Modifier 57 indicates that the decision for surgery occurred during an E&M encounter. It is not used with minor surgeries. E&M services appended with Modifier 57 are only eligible for reimbursement if they represent the initial decision for surgery. Any E&M service performed the day before or the day of a major surgery but also appended with Modifier 57 requires evidence that the decision for surgery was completed at that time and had not been previously planned. Additionally, it is inappropriate for providers to bill Modifier 57 if the decision for surgery occurred at a previous E&M service. In that scenario, the E&M service, even though appended with Modifier 57, will not be eligible for reimbursement.
• Staged Procedures should be appended with Modifier 58. Unplanned returns to the operating room for a related procedure during the postoperative period should be appended with Modifier 78. Likewise, unrelated procedures that are performed during the global surgical period should be appended with Modifier 79. When appending procedures with Modifier 58, 78, or 79 during a 90 day or 10 day postoperative period of a previous major or minor surgery, there must be sufficient documentation supporting the use of one of the aforementioned modifiers for that procedure to be eligible for reimbursement outside of the global surgical package.
• Procedures billed in an office setting during a global period with the same procedure code will be understood to represent postoperative care and will be subject to global reimbursement rules.
• Repeat surgical procedure(s) by the same surgeon performed on the same day as the original surgery, requiring a return trip to the operating room should be appended with Modifier 76. Documentation must support the use of this modifier and provide the necessary detail in order for a service to be eligible for reimbursement.
• Repeat surgical procedure(s) by a different surgeon, on the same day as the original surgery, requiring a return trip to the operating room should be appended with Modifier 77. Documentation must support the use of this modifier and provide the necessary detail in order for a service to be eligible for reimbursement.

Rationale

Consistent with CMS, Blue Cross NC’s global payment for surgical procedures is inclusive of all related services. Blue Cross will consider additional reimbursement for unrelated services consistent with the content of this policy.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Related policy

Bundling Guidelines

Modifier Guidelines

Split Surgical Packages

References

Healthcare Common Procedure Coding System

American Medical Association, Current Procedural Terminology (CPT®)

Centers for Disease Control and Prevention, International Classification of Diseases, 10th Revision

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf

Centers for Medicare & Medicaid Services. Global Surgery Booklet. https://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual, Chapter 12, Section 40, Surgeons and Global Surgery. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/InternetOnly-Manuals-IOMs-Items/CMS018912

History

6/1/2022 - New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/2022 - Routine Policy Review. Minor revisions only. (cjw)

7/18/2023 - Non-physician practitioners reimbursement of a Major Procedure (90 day) language added to Reimbursement Guidelines. Medical Director approved. Notification on 7/18/2023 for effective date 9/18/2023. (tlc)

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.