Understanding the Global Surgery Package: What Can and Cannot Be Billed

The global surgery package is one of the most frequently misunderstood concepts in surgical billing — and one of the most expensive to get wrong. Billing for services that are included in the global package results in overpayment, potential recoupment, and audit risk. Failing to bill for legitimate services that fall outside the global package leaves revenue on the table.

This guide explains exactly what the global surgery package includes, which global period applies to which procedures, when you CAN bill separately for services rendered during the global window, and how to document each scenario correctly.

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What Is the Global Surgery Package?

When CMS and most commercial payers reimburse a surgical procedure, the payment is a "package" that bundles together:

1. The surgical procedure itself
2. Pre-operative care performed on the day before surgery (and the day of surgery if the decision to operate was made earlier)
3. Post-operative care for a defined number of days after the procedure

The single payment for the surgery is intended to cover all of these services. If you bill separately for services that are included in the global package, you are double-billing — and payers will deny those claims or demand repayment.

The global surgery policy was developed by CMS as part of the Resource-Based Relative Value Scale (RBRVS) system implemented in 1992. The concept was based on typical practice patterns — the idea that surgeons routinely provide pre-operative evaluation and post-operative management as part of the complete surgical service, so the single surgical fee should encompass all of it.

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Three Global Period Types (Plus XXX)

0-Day Global (Zero Global)

The 0-day global period includes only same-day pre- and post-operative care. It applies to:

• Endoscopic procedures (colonoscopy, EGD, bronchoscopy)
• Minor outpatient procedures designated "000" in the Medicare Physician Fee Schedule
• Injections and minor diagnostic procedures

What this means practically: A post-op office visit the very next day after a zero-global procedure is separately billable. There is no "post-op window" for these procedures beyond the day of service. If you perform a colonoscopy (45378) on Monday and the patient returns on Tuesday for a complication evaluation, you bill a standard E/M.

10-Day Global

The 10-day global period covers the day of surgery plus 9 post-operative days. Applies to minor surgical procedures including:

• Carpal tunnel release (64721)
• Trigger finger release (26055)
• Ganglion cyst excision (25111, 26160)
• Skin excisions and simple wound closures
• Injections with longer recovery expectations

Post-op visits on day 11 and beyond are separately billable. Within the 10-day window, routine post-op care (wound check, suture removal, progress assessment) is bundled.

90-Day Global

The 90-day global period is the most consequential and covers:

• The day before surgery
• The day of surgery
• 90 post-operative days

Applies to all major surgical procedures including total joint replacements, spinal fusions, open fracture reductions, abdominal surgeries, cardiac procedures, and most procedures requiring general anesthesia. The 90-day window is a long period — for a total knee replacement performed in January, the global period extends through April.

No Global Period ("XXX" or "YYY")

Some procedures have no global period at all. The CPT manual designates these as "XXX" — the global surgery concept does not apply. Services around these procedures are always separately billable. Examples include many diagnostic tests, E/M services themselves, and procedures for which CMS has specifically excluded the global package concept.

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What Is Included in the Global Package

Pre-Operative Services (Included)

The following are included in the surgical fee and cannot be billed separately:

• E/M visit on the day before surgery if the purpose is surgical preparation or workup directly related to the planned procedure. Note: this applies to the surgeon's own pre-op evaluation — not a separate internist's pre-op clearance visit (which is separately billable).
• E/M visit on the day of surgery — included regardless of when in the day it occurs.
• Medical clearance by the operating surgeon — if the surgeon does their own H&P, it's bundled. If a separate physician (primary care, cardiologist) does the medical clearance, that physician bills separately.
• Routine pre-op preparation such as reviewing test results and imaging directly related to the planned procedure.

What this does NOT include: Pre-operative care rendered by a physician other than the operating surgeon, pre-operative diagnostic studies ordered by the surgeon (labs, EKG, X-rays — separately billable), and the initial evaluation visit where the decision to operate was made (separately billable with modifier -57 for major surgery).

Intraoperative Services (Included)

• The procedure itself, including all standard techniques required to perform it
• Local/topical anesthesia administered by the surgeon: included in the surgical fee. Anesthesia provided by a separate anesthesiologist or CRNA is billed separately by that provider.
• Dictating and signing the operative report
• Usual and necessary supplies (sutures, skin staplers, dressings for wound closure). Implants and specialized hardware (joint prostheses, bone screws, plates, pacemakers) are NOT included and can be billed separately.

Post-Operative Services (Included)

The following services rendered within the global window are included and cannot be billed separately:

• Routine post-op office visits for follow-up directly related to the surgical condition
• Wound checks and dressing changes when uncomplicated
• Suture and staple removal by any provider within the same practice group
• E/M visits for expected outcomes of the procedure (expected pain, swelling, limited range of motion)
• Post-operative X-rays taken to evaluate the result of surgery (e.g., post-op knee X-ray to confirm prosthesis position)
• Minor incision-related treatments that don't require a separate surgical procedure (e.g., wound cleaning, applying wound closure strips)

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What Is NOT Included in the Global Package

This is where practices leave significant revenue uncollected. The following services, even when rendered during the global window, are separately billable — but require the correct modifier.

1. Services Unrelated to the Surgery

If a patient has a total knee replacement and presents during the 90-day global period with an unrelated problem — a sinus infection, hypertension management, a skin rash, or a separate injury — that service is not part of the global package.

Modifier -24 (Unrelated evaluation and management service by the same physician during a post-op period):

• Append to the E/M code
• The diagnosis for the unrelated service must be clearly different from the surgical diagnosis
• The medical record must document that the visit was for a condition unrelated to the surgery

Documentation example: "Patient presents for post-operative follow-up. Also evaluated for acute onset of left shoulder pain, a new, unrelated problem. Shoulder evaluation: [clinical assessment]. Impression: Left shoulder rotator cuff tendinopathy, unrelated to prior right knee replacement. [Separate management plan]."

Critical: The ICD-10 codes must reflect the unrelated condition. If both the surgical diagnosis and the visit diagnosis are "M17.11" (primary osteoarthritis, right knee), a payer will deny the -24 claim as bundled even if the intent was unrelated care.

2. Complications Requiring Significant Additional Treatment

When a post-operative complication is serious enough to require a significantly separate procedure or service, the complication treatment is separately billable.

Modifier -78 — Return to the operating or procedure room by the same physician for a complication during the post-op period. The complication IS related to the original surgery.

• Payment: Reduced (only the intraoperative component of the surgical fee is paid; no new global period starts)
• Requires: Separate operative report documenting the complication and treatment

Modifier -79 — Return to the OR for an unrelated procedure during the post-op period.

• Payment: Paid at full procedure rate; a NEW global period starts
• Requires: Documentation confirming the second procedure was unrelated to the first

Example using -78: Patient has an elective knee arthroscopy (29881) with a 90-day global period. On post-op day 8, the patient develops a wound hematoma requiring operative evacuation. The evacuation is performed in the OR. Bill: Hematoma evacuation code + modifier -78. The hematoma was a complication of the original arthroscopy — related complication.

Example using -79: During the 90-day global period after a right knee replacement, the patient falls and fractures their left wrist, requiring ORIF. The ORIF is completely unrelated to the knee replacement. Bill: Radius ORIF code + modifier -79. A new 90-day global period begins for the wrist ORIF.

3. The Decision for Major Surgery

When the surgeon evaluates a patient and makes the decision to perform a major procedure during a separately identifiable E/M visit (not the day of surgery), that E/M is separately billable.

Modifier -57 — E/M visit = the decision for major surgery

• Used specifically for procedures with 90-day global periods
• Applicable when the decision to operate was made during an encounter the day before or the day of surgery
• Commonly used for urgent/emergent presentations where surgery was not previously planned

Classic scenarios for modifier -57:

1. Patient presents to the orthopedist's office with an acute fracture. The surgeon evaluates, decides surgery is necessary, and the patient is taken to the OR later that day or next morning. The initial office evaluation = E/M with modifier -57.
2. A general surgery patient has a routine follow-up for chronic abdominal pain. During the visit, new imaging reveals an acute finding requiring urgent cholecystectomy. The visit where this decision was made = E/M with modifier -57.

Common mistake: Forgetting modifier -57 when it applies, thereby losing a billable E/M visit. Also common: using modifier -57 when modifier -25 is the correct modifier (for minor procedures where the decision is inherent in the pre-procedure assessment).

4. Staged Procedures

A second procedure planned at the time of the original surgery — or a necessary second phase of a multi-stage operation — is separately billable with modifier -58.

Modifier -58 — Staged or related procedure during the post-op period

• Use when: the second procedure was planned at the time of the first (staged); the original procedure was therapeutic but follow-up surgery was required; the procedure is more extensive than the original
• Payment: A NEW global period begins for the second procedure

Example: A colorectal surgeon performs a hemicolectomy for cancer with a temporary colostomy. Sixty days later, during the 90-day global period, the colostomy reversal is performed. The reversal was planned at the time of the original resection. Bill: colostomy reversal code + modifier -58.

Example: A burn patient undergoes primary wound debridement. Three weeks later, a skin graft is placed during the global window of the debridement. Bill: skin graft code + modifier -58.

5. Significantly Complex Post-Operative Complications

Minor complications (expected wound seepage, mild infection responding to oral antibiotics) are included in the global package. When a complication requires:

• A return to the OR (bill with -78)
• Extended IV antibiotic management and prolonged hospitalization
• Wound care so extensive it constitutes a separately significant service

...the complication management may be separately billable with thorough documentation. This is a gray area — the service must be clearly above the level of "routine post-op management."

6. Services by a Different Physician Group

The global period applies to the operating surgeon and their group practice. If a physician from a different practice group treats the patient during the global period — even for the same surgical condition — that physician can bill separately because the global period doesn't extend to other groups.

Example: Hospital-employed hospitalists managing a patient post-operatively for a community surgeon's global period can bill their hospital E/M codes — the global package doesn't apply to them.

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Global Period Modifiers: Complete Reference

Modifier	Description	When to Use	Payment Effect
-24	Unrelated E/M during post-op period	E/M for different condition during global	Full E/M payment
-25	Significant, separate E/M same day as minor procedure	Truly separate E/M before minor procedure	Full E/M payment
-57	E/M = decision for major surgery	Initial evaluation that led to major surgery decision	Full E/M payment
-58	Staged/related procedure during post-op period	Planned second-stage procedure	Full procedure payment; new global starts
-78	Return to OR for related complication	Complication requiring OR return	Reduced (intraoperative component only)
-79	Return to OR for unrelated procedure	Unrelated second surgery during global	Full procedure payment; new global starts

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Modifier -25: E/M Same Day as a Minor Procedure

While technically not part of the 90-day global discussion, modifier -25 is the most commonly misused surgical modifier.

The Rule

When a physician performs a minor procedure AND a separately significant E/M service on the same day, the E/M can be billed in addition to the procedure — but only if the E/M was:

1. Significant and separately identifiable from the decision to perform the minor procedure
2. Beyond the usual pre- and post-procedure work already included in the procedure's fee

Modifier -25 tells the payer that the E/M was a real, medically necessary service, not just the brief pre- and post-procedure assessment bundled into the procedure code.

Valid vs. Invalid Modifier -25 Use

Valid: A patient with knee pain presents. The physician evaluates the knee fully, reviews imaging, documents a complete history and physical exam assessing multiple differential diagnoses, and injects the knee joint (20610). The E/M visit (99213 or 99214) was a real, documented encounter that was more than the usual "brief pre-service assessment." Billing: 99213-25 + 20610.

Invalid: A patient comes in specifically for a scheduled injection, already evaluated at a prior visit. The physician performs the injection, documents only the injection details, and does nothing beyond routine pre/post-procedure assessment. The E/M is NOT separately billable — it's bundled into the procedure code.

The documentation test: If you removed the E/M note from the chart, would there be a complete clinical note documenting the visit independently? If yes, the E/M is separately identifiable. If the only documentation is the procedure note, the E/M is bundled.

High-Audit Areas for Modifier -25

The OIG has consistently flagged modifier -25 as a high-risk billing area. Practices that bill -25 on 80–90% of same-day procedure visits are audit targets. The benchmark: if your procedure-volume practice is attaching -25 to nearly every injection or minor procedure, document carefully — each one should be clinically justifiable.

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Global Period Reference Table: Common Procedures by Specialty

Orthopedics

CPT Code	Procedure	Global Period
27447	Total knee arthroplasty	90 days
27130	Total hip arthroplasty	90 days
29888	ACL reconstruction	90 days
29881	Knee arthroscopy, meniscectomy	90 days
23472	Total shoulder arthroplasty	90 days
22612	Lumbar fusion, posterior	90 days
22851	Spinal instrumentation (add-on)	ZZZ
64721	Carpal tunnel release	10 days
26055	Trigger finger release	10 days
20615	Aspiration of cyst	10 days
20610	Aspiration/injection, major joint	0 days
20600	Aspiration/injection, small joint	0 days

General Surgery

CPT Code	Procedure	Global Period
47562	Laparoscopic cholecystectomy	90 days
49505	Inguinal hernia repair (reducible)	90 days
44950	Appendectomy	90 days
43239	EGD with biopsy	0 days
45378	Colonoscopy, diagnostic	0 days
45380	Colonoscopy with biopsy	0 days
45385	Colonoscopy with polypectomy	0 days
10120	Removal of foreign body, superficial	10 days
10060	Incision and drainage, abscess	10 days

OB/GYN

CPT Code	Procedure	Global Period
58150	Total abdominal hysterectomy	90 days
58571	Laparoscopic hysterectomy	90 days
59400	Vaginal delivery, global OB package	Maternity (MMM)
59510	Cesarean section, global OB package	Maternity (MMM)
58100	Endometrial biopsy	0 days
57511	Cryosurgery of cervix	10 days
58300	IUD insertion	0 days

Urology

CPT Code	Procedure	Global Period
52601	TURP	90 days
50947	Laparoscopic pyeloplasty	90 days
55040	Hydrocelectomy	90 days
52310	Cystoscopy with removal of foreign body	0 days
52204	Cystoscopy with biopsy	0 days
55250	Vasectomy	10 days

ENT (Otolaryngology)

CPT Code	Procedure	Global Period
21085	Rhinoplasty	90 days
31287	Functional endoscopic sinus surgery (FESS)	90 days
42820	Tonsillectomy + adenoidectomy	90 days
31575	Laryngoscopy with biopsy	0 days
69210	Removal of impacted cerumen	0 days

Ophthalmology

CPT Code	Procedure	Global Period
66821	YAG laser capsulotomy	90 days
67210	Photocoagulation, retinal	10 days
65710	Keratoplasty	90 days
66984	Extracapsular cataract with IOL	90 days
67028	Intravitreal injection	0 days

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The Financial Impact of Global Period Errors

Understanding the dollar impact of global period billing errors helps prioritize compliance and correction efforts.

Scenario A: Billing Post-Op Visits Without a Modifier (Overpayment)

Practice: 3-surgeon orthopedic group performing 200 major cases per year (90-day global) Error: Billing one 99213 post-op visit per patient without recognizing it's bundled Average overpayment per visit: ~$75 (Medicare non-facility rate for 99213) Annual overpayment: 200 visits × $75 = $15,000 Risk: Payer audit, recoupment with interest, potential compliance referral

Scenario B: Not Billing Services That ARE Separately Payable (Revenue Loss)

Practice: Same 3-surgeon group Missed opportunities:

• Failing to use modifier -57 for 20 emergency pre-op evaluations/year: 20 × $155 = $3,100
• Failing to use modifier -24 for 30 unrelated visits during global periods/year: 30 × $120 = $3,600
• Failing to use modifier -58 for 10 staged procedures/year: 10 × $1,200 = $12,000
• Total missed revenue: $18,700/year

The financial case for understanding global period rules is clear: both over-billing (audit risk) and under-billing (revenue loss) cost practices real money.

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Commercial Payer Differences

Medicare's global surgery package rules are the standard framework, and most commercial payers follow the same rules — but variations exist:

UnitedHealthcare: Generally follows CMS global package rules. Some commercial plans have different global period lengths for select procedures. Check the provider manual.

Aetna: Generally follows CMS. Has specific policies on multiple procedure payment that sometimes differ from CMS's 100%/50% rule.

Anthem BCBS: Varies by state. Some BCBS plans have contracted "global periods" that differ from CMS.

Cigna: Closely follows CMS but has additional documentation requirements for modifier -25 claims.

Self-insured employer plans: Governed by plan documents, not state insurance law. May have unique global period rules. Always verify with the payer.

Key principle: CMS rules are the floor and most common framework, but when in doubt about a commercial payer's specific rules, call their provider relations line or review their provider manual. Documentation requirements for modifiers like -25 and -57 should always be thorough regardless of payer.

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Documentation Requirements by Modifier Type

For Modifier -24 (Unrelated E/M)

The medical record must clearly show:

• The unrelated diagnosis (ICD-10 code different from surgical diagnosis)
• A complete E/M note for the unrelated condition
• Documentation that the surgeon evaluated and managed a condition separate from the surgical site
• Ideally, a statement in the note: "This visit is for [unrelated condition], separate from the patient's postoperative care for [surgical diagnosis]."

For Modifier -25 (Separate E/M Same Day as Minor Procedure)

The medical record must clearly show:

• A complete, separately identifiable E/M note (not just the procedure note)
• Documentation of the problem, history, examination, and medical decision-making that justified the E/M
• A clinical reason that the E/M was more than just the typical pre-procedure assessment

For Modifier -57 (Decision for Major Surgery)

The medical record must clearly show:

• The presenting problem and clinical findings
• The decision made during this encounter to recommend major surgery
• Documentation of the discussion with the patient regarding the surgical plan
• Informed consent initiation (often documented here)

For Modifier -58 (Staged Procedure)

The medical record for the first procedure must document:

• That a second procedure is planned or anticipated
• The reason for staging (patient condition, cancer staging, planned approach)

The operative note for the second procedure should reference the first procedure and confirm its staged, related nature.

For Modifier -78 (Return to OR — Related Complication)

The documentation must show:

• The nature of the complication
• The clinical necessity for returning to the OR
• A separate operative report for the complication procedure
• Confirmation that the complication was related to the original procedure

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Common Global Period Billing Errors and Fixes

Error 1: Post-Op Visit Billed Without Checking Global Status

Problem: A billing staff member sees a post-op appointment and bills a standard 99213. The procedure has a 90-day global — the visit is bundled. Fix: Flag every surgical patient's account in your PM system with the global end date. Configure alerts so billers see the global status when processing charges from post-op visits.

Error 2: Missing Modifier -57 for Pre-Op Decision Visits

Problem: An orthopedic surgeon evaluates a fracture patient, makes the decision to operate, and performs the ORIF the next day. The pre-op evaluation is not billed because the coder assumes it's bundled. Fix: Train providers to indicate on the superbill: "Decision for surgery made at this visit: Y/N." If yes, add modifier -57 to the E/M code.

Error 3: Not Billing Staged Procedures with -58

Problem: A general surgeon performs a Hartmann's procedure (sigmoid resection with end colostomy) and three months later does the colostomy reversal during the global period. The reversal is not billed because the biller sees the patient is in a global period. Fix: Educate billing staff that staged procedures within the global period are separately billable with modifier -58. Create a "staged procedures" flag in the patient account.

Error 4: Wrong Modifier on OR Return

Problem: A return to OR for a wound infection (related complication) is billed with modifier -79 (unrelated) instead of -78 (related complication). The claim is denied or overpaid. Fix: Create a modifier decision tree for OR returns: "Is the reason for returning to the OR related to the original surgery? If yes → -78. If no → -79."

Error 5: Billing Lab/Imaging That's Bundled

Problem: A post-op X-ray to assess prosthesis position after total knee replacement is billed in addition to the global surgical fee. Fix: Only bill post-op imaging separately if it is for an unrelated condition or if the payer specifically carves out imaging from the global package (rare). Review your billing for patterns of post-op imaging claims during global periods.

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Tracking Global Periods: Workflow Recommendations

Effective global period tracking requires:

1. At time of surgery: Enter the global period end date into the patient's account in the PM system. Most modern PM systems have a "global end date" field.

2. At scheduling: When a post-op patient schedules an appointment, the scheduler should see the global status indicator and communicate to the provider that the visit may be within the global window.

3. At billing: The biller reviews the global status before processing charges from any post-op visit. If within global: is a modifier warranted? If yes, which one and why?

4. Monthly audit: Run a report of claims submitted by patients with active global periods. Flag any E/M claims without modifiers for review.

5. Staff education: Any biller, scheduler, or provider who handles surgical patients needs global period training annually. Global period errors are one of the top OIG audit findings for surgical practices.

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Frequently Asked Questions About the Global Surgery Package

Q: How do we know which global period applies to a procedure? Look up the procedure code in the Medicare Physician Fee Schedule (MPFS). The "Global Days" column shows "000" (zero global), "010" (10-day), "090" (90-day), "MMM" (maternity), "YYY" (decision for treatment requires pre-procedure evaluation), or "XXX" (global concept does not apply). CMS publishes the complete fee schedule at cms.gov. Commercial payer fee schedules may differ — check their provider manuals.

Q: What happens if we accidentally bill during the global period without a modifier? If the payer catches it on adjudication, they will deny the claim. If they pay it and later audit, they will demand repayment with interest. Widespread patterns of billing during global periods without modifiers can trigger OIG referrals. Proactively identifying and refunding overpayments (voluntary disclosure) is far better than waiting for audits.

Q: Does the 90-day global period apply to commercial payers too? Most commercial payers follow Medicare's global surgery package rules, but not all. Some commercial payers use different global periods or different inclusions/exclusions for specific procedures. Review each payer's provider manual and verify when billing unusual situations. When in doubt, call the payer's provider relations line.

Q: Can an NP or PA bill separately for post-op visits during a surgeon's global period? If the NP or PA is employed by the same group practice as the surgeon, no — services by members of the same group practice are bundled into the global. If the NP or PA is employed by a different practice (e.g., a hospitalist group), they can bill separately.

Q: When a patient has surgeries from two different surgeons, do the global periods overlap? Each surgeon has their own global period for their own procedures. A cardiologist performing a cardiac catheterization and an orthopedic surgeon performing a knee replacement on the same patient each has their own independent global period. The global periods don't interact with each other.

Q: How does the global period work for assistant surgeons? The assistant surgeon's fee is also subject to the global package rules. The assistant cannot bill separately for post-operative care of the case they assisted on. The primary surgeon's global period and the assistant surgeon's global period run concurrently for the same procedure.

Q: What if surgery is canceled or aborted? If a patient is prepped, anesthesia is administered, but surgery is aborted due to a medical condition discovered intraoperatively, use modifier -53 (discontinued procedure) on the CPT code. Document the reason for discontinuation. Payment is reduced proportional to the work performed. No global period is triggered for an aborted procedure.

Q: Does the global period apply to telehealth post-op visits? Post-op telehealth visits during the global period are treated identically to in-person visits — they are included in the global fee if they are routine post-operative care. With modifier -24 (unrelated condition), a telehealth post-op E/M is separately payable. Use appropriate telehealth codes and POS designations, and verify the specific payer's telehealth billing policy for post-op services.

Q: Can we bill for physical therapy ordered during the global period? Physical therapy services (billed by a physical therapist) are not part of the surgeon's global package — they are separate services provided by a different professional. The PT bills their own codes regardless of where the patient is in the surgeon's global period. However, if the surgeon performs any therapeutic procedures (injections, manipulation) during the global window for the same condition, those are bundled.

Q: What is the penalty for systematic global period billing errors? The False Claims Act imposes penalties of $13,946–$27,894 per false claim plus up to three times the amount of damages. For a practice that has been billing E/M codes during global periods without modifiers across hundreds of patients over several years, cumulative liability can reach six or seven figures. The risk is serious enough to warrant regular compliance audits of global period billing.

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Building a Global Period Compliance Program

For surgical practices with significant procedure volume, a structured compliance program for global period billing is essential:

1. Annual training: All billing staff, coders, and physicians handling surgical charges receive global period training each year — updated for any CMS changes.

2. PM system configuration: Global period end dates populated for every major procedure; alerts triggered when charges are billed for patients in active global periods without modifiers.

3. Modifier policy documentation: Written policies for when each surgical modifier (-24, -25, -57, -58, -78, -79) should be applied, with examples specific to your specialty.

4. Quarterly audit: Sample 20–30 post-op charts quarterly. Verify that billed E/M visits during global periods were appropriate (billed without modifier only if bundled; billed with correct modifier if legitimately separate). Track error rates.

5. Payer-specific crosswalk: Maintain a payer-by-payer matrix of global period rules for your top 5 payers — differences from CMS standard are documented and communicated to billing staff.

The investment in global period compliance pays for itself through reduced audit risk, fewer recoupment demands, and the capture of legitimately billable services that were previously being left on the table.

If your practice needs a global period billing audit or wants to implement a structured compliance program, contact Healix RCM for a consultation.