Billing the Global Surgical Package
Medicare, Medicaid, and third-party commercial insurers employ the concept of a global surgical package when reimbursing surgeons for specific medically necessary services that they provide to patients under their care. What this means is that certain services are incidental to the main procedure, or that they are considered an integral component of that surgical procedure. This includes both evaluation and management services, as well as physical interventions that may be required in order for the procedure to be successful.
Global Surgical Periods
The Medicare Claims Processing Manual defines the global surgical package concept in Chapter 12, Section 40.1. The global period is defined for each surgical Healthcare Common Procedural Coding System (HCPCS) code. It can be zero or ten days following a surgical procedure for minor procedures or endoscopies, or it can be ninety days for major surgeries. This means that all services provided to a patient that included in the global package that provided during this period are considered integral to the global package.
The approved amount for any surgical procedure defined by a HCPCS code is reimbursed by considering all the elements that go into successfully completing the service. This includes pre-operative visits to the surgeon after the initial visit during which the surgeon determines that surgical intervention is the most appropriate care option for the patient’s condition. The clock begins the day before surgery for major operations, and the day of surgery for minor operations. When surgery is scheduled, all evaluation and management services relating to the surgical condition are bundled into the global surgical package.
The Global Surgical Package
Consistent with this, all intra-operative services that the surgeon performs are considered a necessarily important part of the surgical procedure. Evaluation performed in the operating suite is not coded or billed separately. The HCPCS code for the procedure includes everything that happens while the procedure is being performed.
After the surgical procedure is concluded, any services that a surgeon provides to deal with anticipated or unanticipated complications relating to the surgery are considered part of the global surgical package. For major operations, this means that complications that occur within ninety days after the procedure was completed are bundled into the initially reported code. For minor operations, complications that occur within ten days after the surgery are considered integral with dealing with the patient’s immediate care. For the least invasive operations, such as endoscopies, in which the incidence of complication are very low, and that carry a global period of zero, next day complications can be coded and billed for appropriate reimbursement. These guidelines include all post-operative visits related to the surgery, as well as post-surgical pain management.
Supplies that a surgeon employs to perform a surgery are considered an integral component of the applicable HCPCS code. This includes dressings, drains, casts, suture material, catheters, and anesthesia delivered by the surgeon, though not services provided by a separate anesthesiologist. The operation cannot be performed without these supplies, and their cost is factored into the fee that third-party payers assign to specific HCPCS codes for each surgical procedure.
Just as follow evaluation and management of the complications that follow surgeries is considered integral to major surgeries, the same is true of miscellaneous services that follow an operation. The removal of drains, changing dressing, splints, casts, and changing or maintaining nasogastric tubes, urinary catheters, and tracheostomy tubes are likewise bundled into both routine, and non-routine, post-operative management. For instance, though procedural codes exist for the placing a urinary catheter, if it takes place during the global surgical period, this service is not coded for reimbursement purposes.
What the Global Surgical Package Does Not Include
The initial consultation that a surgeon performs to determine the need for a major surgical intervention is not a part of the global surgical package. When it is determined that a minor surgical procedure is indicated, the initial evaluation and management is included in the allowable reimbursement for the procedure unless there is management above and beyond the performance of the procedure and its immediate effects on the patient.
Within the global period, a patient may present with symptoms or conditions that are unrelated to the surgery or to the condition for which the surgery was performed. These services are not bundled into the surgical package. They are coded and billed accordingly, with a modifier -25 appended to the relevant HCPCS code to indicate that distinct service was performed separate from the main reason for the patient encounter.
Diagnostic tests and procedures, including diagnostic radiology, are likewise not bundled into the global surgical package. Neither are distinct surgical procedures that are unrelated to the main procedure.
There are other exceptions to the global surgical package concept, but these are the most common. Professional medical billers and certified medical coders who have received the appropriate training from a credentialed learning program are aware of these issues. They prevent surgeons from unbundling services that are included in the global surgical package for reimbursement. Unbundling services is an aspect of medical claims fraud that is watched closely by third-party payers. By reducing the risk of being accused of fraudulent billing, professional medical billers and medical coders who specialize in surgery ensure that their employers receive the maximum legal reimbursement for their services without abusing the system and subjecting themselves to legal exposure.