MCW_ Reimbursement Complexity for Global Surgical Packages

Reimbursement Complexity for Global Surgical Packages

Current coding policies dictate reimbursement complexity for global surgical packages primarily by defining which services are bundled (included in the single payment), which services must be unbundled (reported separately with a modifier), and how payment models are structured based on the setting of care.

The complexity of reimbursement is managed through strict application of the Medicare National Correct Coding Initiative (NCCI) rules, CPT guidelines, and specialized global surgery modifiers.

1 . Definition and Scope of the Global Package

A Global Surgical Package includes all necessary professional services normally furnished by a physician or members of the same group practice with the same specialty before, during, and after a procedure. Complexity is first classified by the procedure’s global period:

• Major Surgical Procedure (090 days): Includes one day before surgery, the day of surgery, and 90 days following the surgery day, totaling 92 days.
• Minor Surgical Procedure (010 days): Includes the day of surgery and 10 days following the procedure.
• Minor Surgical Procedure/Endoscopy (000 days): Has a 0-day post-operative period.

2 . Bundling Complexity (Included Services)

To simplify reimbursement, many services integral to the surgical episode are bundled into the primary procedure’s payment and are not separately reportable. These bundling rules reduce complexity by preventing improper unbundling and multiple claim submissions for routine care.

Stage	Services Included in the Global Package (Not Billable Separately)	Sources
Preoperative	Visits after the decision to operate is made, starting the day of or day before major surgery, unless billed with Modifier -57.
Intraoperative	Routine steps necessary for the procedure, such as obtaining exposure (e.g., laparotomy for colectomy), insertion of urinary catheters, wound closure (simple, intermediate, or complex), supplies, local anesthesia, and control of bleeding.
Intraoperative Check	An endoscopic procedure performed solely to ensure no intraoperative injury occurred or to verify the procedure was correctly performed (e.g., verification cystourethroscopy).
Postoperative	All medical or surgical services required by the surgeon to treat complications that do not require an unplanned return to the operating room. Routine follow-up visits related to recovery, dressing changes, and routine removal of sutures/drains are included.

3 . Complexity Management Through Modifiers (Unbundled Services)

The primary method for managing reimbursement complexity when non-routine services are performed is the accurate application of Global Surgery Modifiers. These modifiers bypass bundling edits to ensure justified separate payment:

• Modifier -57 (Decision for Major Surgery): Used when an E/M service leads to the initial decision to perform a major surgical procedure (090 global) on the day of or the day before the surgery. This modifier enables separate reimbursement for the cognitive work.
• Modifier -25 (Separate E/M): Used for a significant, separately identifiable E/M service performed on the same day as a minor surgical procedure (000/010 global). This ensures the E/M work that is above and beyond the usual preoperative work is reimbursed.
• Modifier -79 (Unrelated Procedure): Used when the same physician performs a procedure during the global period that is unrelated to the original surgery. This initiates a new global period and results in 100% allowable payment for the second procedure.
• Modifier -78 (Unplanned Return to OR): Used when the same physician returns the patient to the operating room (OR) to treat a related complication. This reflects complexity by allowing separate payment, but limits reimbursement to the intra-operative portion only (e.g., 70%) and does not start a new global period.
• Transfer of Care Modifiers (-54, -55, -56): Used when care responsibilities are formally or informally split between providers for procedures with 010 or 090 global periods. For CY 2025, CMS is broadening the application of Modifier -54 (Surgical Care Only) for 90-day global packages, applying it even for informal or expected transfers of post-operative care.

4 . Reimbursement Complexity Based on Setting

The complexity of payment is significantly influenced by the setting, which determines the entire reimbursement methodology:

Setting	Reimbursement System & Complexity Factor	Sources
Professional (Physician)	Medicare Physician Fee Schedule (MPFS) / CPT: Reimbursement is based on Relative Value Units (RVUs) and dictates professional payment using CPT codes and global modifiers. Complexity is reflected by the necessity of Modifier -22 (Increased Procedural Services), which may justify additional payment (e.g., 125% of normal allowance) for services substantially greater than usual due to factors like excessive blood loss, trauma, or unusually lengthy procedures.
Hospital Inpatient	Inpatient Prospective Payment System (IPPS) / MS-DRGs: Facility payment is a lump-sum package determined by the assigned Medicare Severity-Diagnosis Related Group (MS-DRG). Complexity is driven by documenting the principal procedure (ICD-10-PCS) and the presence of Complications/Comorbidities (CCs) or Major Complications/Comorbidities (MCCs), which significantly increase the payment weight (Relative Weight) for the entire stay.
Hospital Outpatient (HOPD)	Outpatient Prospective Payment System (OPPS) / APCs: Facility reimbursement relies on Ambulatory Payment Classifications (APCs), characterized by extensive packaging of ancillary services (drugs, supplies, low-level services) into the primary APC payment. Complexity may be addressed through Complexity Adjustments for qualifying paired code combinations (e.g., primary service plus specific add-on codes) that are determined to be sufficiently costly and frequent, potentially promoting the claim to a higher paying APC within the clinical family.
Ambulatory Surgical Center (ASC)	ASC Payment System: ASC payments are generally lower than OPPS rates and involve high levels of bundling. Add-on codes are typically packaged and do not receive separate payment. To address complexity, CMS proposed a special payment policy for CY 2023 where complex code combinations eligible for OPPS complexity adjustments are assigned new C codes to allow for a higher payment rate, mitigating financial disincentives for complex services in ASCs.
Multiple Procedures	Multiple Procedure Payment Reduction (MPPR): When multiple surgical procedures are performed in the same session, reimbursement is reduced. The highest valued procedure receives 100% of the allowable amount, but subsequent procedures (second through fifth) typically receive 50% of their allowance. Procedures reported with Modifier -78 are not subject to the multiple procedure concept.

The ongoing effort to improve global surgery payment accuracy includes soliciting comments regarding the valuation of the global surgical package, especially concerning the division of work between surgeons and providers of post-operative care and the use of transfer of care modifiers. The CMS also mandated data collection on post-operative visits to improve the valuation accuracy of global surgical packages.