Crystal's MCW Coder HubGlobal Surgical Package MOC
What Is the Global Surgical Package
The global surgical package is a Medicare and commercial payer policy that bundles a defined set of pre-operative, intra-operative, and post-operative services into a single surgical fee for a given CPT procedure code. When a surgeon bills a surgical CPT code, the reimbursement is intended to cover all services within the global package — separately billing for included services is incorrect and constitutes overbilling.
The global package applies to the operating surgeon only — it does not restrict the billing of other providers (e.g., hospitalists, anesthesiologists, consulting physicians) who independently evaluate or treat the patient.
Global Period Designations
CMS assigns one of the following global period indicators to every CPT surgical code on the Medicare Physician Fee Schedule:
| Indicator | Description | Examples |
|---|---|---|
| 000 | Endoscopic or minor procedure — no pre-op E/M included the day before; no post-op visits included | Intravitreal injection (67028), cerumen removal (69511), punctal plug (68761), diagnostic laryngoscopy (31575) |
| 010 | Minor procedure — includes 1 related E/M visit on day of procedure; all related post-op visits for 10 days after | YAG capsulotomy (66821), tympanostomy tubes (69436), chalazion (67800), epistaxis control (30901/30905), turbinate reduction (30130) |
| 090 | Major procedure — includes pre-op visit 1 day before; all related post-op visits for 90 days after | Cataract (66984), nephrectomy (50220/50230/50546), tonsillectomy (42820/42826), septoplasty (30520), FESS (31254-31298), trabeculectomy (66170), PPV (67036), laryngectomy (31360) |
| MMM | Maternity — global period does not apply in standard way | OB procedures |
| XXX | Global concept does not apply | Diagnostic imaging, pathology, some E/M codes |
| YYY | Payer determines global period | Facility-specific |
| ZZZ | Add-on code — follows primary code global period | Add-on CPT codes always use ZZZ |
What Is ALWAYS Included in the Global Package
Regardless of whether the global period is 010 or 090, the following services are always included in the surgical fee and may NOT be separately billed by the operating surgeon:
Pre-operative:
- One E/M visit the day before major surgery (090 global only).
- On the day of surgery — all E/M visits related to the decision to perform surgery (when the decision was made at a prior encounter — if the decision to operate was made at the same visit as surgery and is separately identifiable, modifier -57 may apply).
Intra-operative:
- All services provided in the operating room or procedure room as part of the surgery.
- Local or topical anesthesia administered by the operating surgeon.
- Topical or local infiltration of anesthetic.
- Writing post-operative orders.
- Evaluating the patient in the recovery room.
Post-operative:
- All routine follow-up visits within the global period related to the surgery.
- Suture, staple, clip, and drain removal.
- Dressing changes performed by the surgeon or surgeon’s staff.
- Management of routine post-operative pain and infection treated conservatively (no return to OR).
What Is NEVER Included — Always Separately Billable
The following services are explicitly excluded from the global package and ARE separately billable:
| Service | Modifier Required | Notes |
|---|---|---|
| Initial decision to perform surgery (when made at separate visit) | -57 | When the decision to operate is made at a separate encounter, not the operative day |
| Diagnostic tests ordered during global period | None | Labs, imaging, pathology — always separately billable |
| Treatment of unrelated conditions during global period | -24 | E/M for conditions unrelated to the surgery |
| Unplanned return to OR for complications | -78 | Post-op hemorrhage, wound dehiscence, infection requiring OR |
| Unrelated surgical procedure during global period | -79 | Different surgical problem during same surgeon’s global period |
| Staged or planned additional procedures | -58 | Planned second-stage procedure known at time of original surgery |
| Critical care services | None | Separately reportable even during global period |
| Other physician or provider services | None | Global package applies only to the operating surgeon |
| Supplies beyond standard post-op care | Appropriate HCPCS | Special wound care materials, grafts billed separately by facility |
| Anesthesia | Anesthesia codes | Billed separately by anesthesiologist or CRNA |
The Decision to Operate — Modifier -57
Modifier -57 is required when:
- An E/M service on the day of or one day before a major surgery (090 global) represents the decision to perform surgery.
- Without modifier -57, the E/M would be bundled into the 090-day global package.
- The E/M must represent a substantive, separately documented encounter at which the surgical decision was made — not simply a routine pre-operative check.
Modifier -57 does NOT apply to minor procedures (000 or 010 global) — for those, modifier -25 is used when an E/M on the same day as the minor procedure is separately identifiable.
| Scenario | Correct Modifier | Global Period |
|---|---|---|
| E/M visit where surgeon decides patient needs cataract surgery — surgery performed same day | -57 on E/M | 090 |
| E/M visit where decision to do tympanostomy tubes is made — tubes placed same day | -25 on E/M | 010 |
| E/M visit where intravitreal injection is administered — patient also has unrelated retinal concern addressed | -25 on E/M | 000 |
Post-Operative Period Modifiers — Full Framework
| Modifier | Full Description | When to Use |
|---|---|---|
| -24 | Unrelated E/M during post-op period | Patient presents during global period for a condition unrelated to the surgery — must use ICD-10 code for the unrelated condition |
| -25 | Significant, separately identifiable E/M on same day as procedure | Most common modifier in ophthalmology (injection + E/M) and ENT (cerumen removal + ETD eval); E/M must be separately documented |
| -57 | Decision for surgery | E/M on day of or day before major (090) surgery at which the operative decision was made |
| -58 | Staged or related procedure during post-op period | Planned second procedure — second eye cataract, second-stage FESS, completion nephrectomy |
| -78 | Unplanned return to OR, same surgeon, related to original surgery | Post-op hemorrhage, wound dehiscence, tube dislodgement — procedure required to manage complication |
| -79 | Unrelated procedure by same surgeon during post-op period | Different surgical site, different problem — no relation to the original surgery |
Split Global — Modifiers -54, -55, and -56
When surgical care is split among different surgeons or providers:
| Modifier | Description | When to Use |
|---|---|---|
| -54 | Surgical care only | Surgeon performs the operation but will NOT provide post-operative care — transfers follow-up to another provider |
| -55 | Post-operative management only | Provider takes over post-operative care after surgery performed by another surgeon |
| -56 | Pre-operative management only | Provider performs and bills for the pre-operative work when a different surgeon will perform the operation |
Example: Patient travels from rural area for surgery. Local ophthalmologist did the pre-op evaluation (-56). Out-of-town surgeon performs cataract surgery (-54). Local ophthalmologist manages all post-op care (-55).
Claims notes:
- Both providers must report the same CPT code.
- The dates of service must reflect when each component of care was provided.
- Payers may prorate the global fee among the providers.
- Some payers do not recognize split global billing — verify payer policy before using -54/-55/-56.
090-Day Global — Visual Timeline
Day -1 Day 0 Day +90 |----------------|-------------------------------| Pre-op E/M SURGERY End of global period (bundled) Intra-op all bundled Recovery room bundled Same-day post-op orders bundled
All related follow-up visits bundled Suture/drain removal bundled Routine post-op pain management bundled
SEPARATELY BILLABLE events:
- Unrelated conditions (-24)
- Return to OR complications (-78)
- Staged planned procedures (-58)
- Unrelated procedures (-79)
- Diagnostic tests (no modifier needed)
Concurrent Care and the Global Package
The global package restricts only the operating surgeon — other providers caring for the patient during the global period bill normally:
| Provider | Restricted by Global Package? |
|---|---|
| Operating surgeon | Yes — all related services bundled |
| Surgical assistant | No — bills separately with -80, -82, or -AS |
| Anesthesiologist/CRNA | No — separate anesthesia codes |
| Hospitalist/internist | No — bills E/M independently |
| Consulting cardiologist | No — consultation or E/M billed independently |
| Physical/occupational therapist | No — therapy codes billed independently |
| Radiologist | No — imaging interpretation billed independently |
| Pathologist | No — surgical pathology billed independently |
Assistant at Surgery — Global Package Interaction
The surgical assistant’s services are NOT bundled into the operating surgeon’s global package. The assistant bills separately using the appropriate modifier:
| Modifier | Provider | Medicare Payable |
|---|---|---|
| -80 | MD/DO surgical assistant | Payable when Medicare MPFS indicator allows; typically 16% of the surgical fee |
| -82 | MD/DO assistant when qualified resident not available | Payable with documentation that a qualified resident was not available |
| -AS | PA, NP, CNS first assist | Payable at 85% of the -80 rate |
Medicare assistant-at-surgery indicator on MPFS:
- 0 — Assistant at surgery not payable (e.g., 50220 simple nephrectomy).
- 1 — Restriction on assistant at surgery does not apply.
- 2 — Assistant at surgery may be payable if documentation of medical necessity is provided.
- 9 — Concept does not apply.
Always verify the current-year MPFS assistant indicator for each CPT code before billing.
Common Global Period Errors — Audit Checklist
- Billing routine follow-up within global period — the most common error; routine wound checks, suture removal, and related post-op care are never separately billable during the global period without a modifier.
- Missing modifier -24 — when treating an unrelated condition during the global period, failure to append -24 will result in a denial or bundling of the E/M.
- Missing modifier -25 — when performing a minor procedure (000 or 010 global) and a separately identifiable E/M on the same day, failure to use -25 results in E/M denial.
- Using -25 instead of -57 — for major (090 global) procedures, the decision-to-operate E/M on the day of or day before surgery requires -57, not -25.
- Billing both the pre-op E/M and the surgery — the day-before E/M for a 090 global procedure is bundled; do not bill it separately.
- Not using -78 for return to OR — complications requiring return to OR within the global period must use -78 or the claim will be bundled or denied.
- Using -79 instead of -78 — -79 is for UNRELATED procedures; -78 is for RELATED complications; using the wrong modifier triggers audit flags.
- Failing to document the separately identifiable service — modifiers -24, -25, and -57 require documentation that clearly supports the separately billed service as distinct from the procedure.
- Billing technical services (injections, dressing changes) within 090 global — nursing or clinical staff services that are part of post-op routine care are bundled; do not bill supply codes for standard dressings.
Global Package by Specialty — Quick Reference
Ophthalmology
| Procedure | Global | Most Common Modifier Issue |
|---|---|---|
| Cataract (66984) | 090 | -58 for second eye; -79 for unrelated eye procedure |
| Intravitreal injection (67028) | 000 | -25 when separate E/M also provided; -LT/-RT laterality |
| YAG capsulotomy (66821) | 010 | Do not bill within 90 days of cataract (bundled in global) |
| Trabeculectomy (66170) | 090 | -78 for bleb leak requiring OR; -58 for staged needling |
| PPV (67036) | 090 | -78 for re-operation; -58 for planned second procedure |
| Ptosis repair (67904) | 090 | -E1-E4 eyelid laterality required |
Otolaryngology
| Procedure | Global | Most Common Modifier Issue |
|---|---|---|
| Tonsillectomy (42820/42826) | 090 | -78 for post-tonsillectomy hemorrhage return to OR |
| Septoplasty (30520) | 090 | -51 when turbinate reduction (30140) added same day |
| FESS (31254/31255/31267) | 090 | -50 for bilateral; -51 for multiple sinus codes same session |
| Tympanostomy tubes (69436) | 010 | -50 for bilateral; -78 for tube revision for complication |
| Cerumen removal (69511) | 000 | -25 when separate E/M; -50 for bilateral |
| Laryngectomy (31360) | 090 | -78 for return to OR; -62 for co-surgeon |
Urology
| Procedure | Global | Most Common Modifier Issue |
|---|---|---|
| Open simple nephrectomy (50220) | 090 | -78 for hemorrhage; -24 for unrelated post-op conditions |
| Open radical nephrectomy (50230) | 090 | -78 for return to OR; -62 for co-surgeon (IVC thrombus) |
| Laparoscopic radical nephrectomy with LND (50546) | 090 | -53 if converted to open; -78 for complication |
| Cystoscopy (52000) | 000 | -25 when separate E/M; -50 if bilateral |
| TURBT (52240) | 010 | -78 for post-TURBT clot evacuation |
Suggested Obsidian Linkouts
- Ophthalmology CPT Codes Reference
- Otolaryngology CPT Codes Reference
- Urology CPT Codes Reference
- Nephrectomy Procedures Family MOC
- Otolaryngology Practice Coding Scenarios
- H20 Iridocyclitis Family MOC
- Procedure Status & Complexity Modifiers
- -24 - Modifier 24
- -25 - Modifier 25
- -54 - Modifier 54, surgical care only
- -55 - Modifier 55, post-operative management only
- -56 - Modifier 56, pre-operative management only
- -57 - Modifier 57, decision for surgery
- -58 - Modifier 58, staged procedure
- -78 - Modifier 78, unplanned return to OR
- -79 - Modifier 79, unrelated procedure during global period
- -80 - Modifier 80, surgical assistant
- -AS - Modifier AS, PA/NP first assist