What services are included in the global surgery payment?
When the physician who furnishes the surgery also furnishes the following services, Medicare includes them in the global surgery payment:
•Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-
operative visits the day before the day of surgery. For minor procedures, this includes pre-operative
visits the day of surgery;
•Intra-operative services that are normally a usual and necessary part of a surgical procedure;
• All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room;
• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery;
• Post-surgical pain management by the surgeon;
• Supplies, except for those identified as exclusions: and
• Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
What services are not included in the global surgery payment?
The following services are not included in the global surgical payment. These services may be billed and paid for separately:
• Initial consultation or evaluation of the problem by the surgeon to determine the need for major
surgeries. This is billed separately using the modifier -57 (Decision for Surgery). This visit may be billed separately only for major surgical procedures:
Note: The initial evaluation for minor surgical procedures and endoscopies is always included
in the global surgery package. Visits by the same physician on the same day as a minor surgery or
endoscopy are included in the global package, unless a significant, separately identifiable service
is also performed. Modifier -25 is used to bill a separately identifiable evaluation and management
(E/M) service by the same physician on the same day of the procedure.
• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications;
Note: A new post-operative period begins with the subsequent procedure. This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure.
• Treatment for post-operative complications requiring a return trip to the Operating Room (OR).
An OR, for this purpose, is defined as a place of service specifically equipped and staffed for
the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a
laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room,
a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would
be insufficient time for transportation to an OR);
• If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;
•Immunosuppressive therapy for organ transplants; and
• Critical care services (Current Procedural Terminology (CPT) codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.
How are minor procedures and endoscopies handled?
Minor procedures and endoscopies have post-operative periods of 10 days or zero days (indicated by 010 or 000, respectively). For 10-day post-operative period procedures, Medicare does not allow separate payment for post-operative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major
surgery on the same day or in the 10-day period, the major surgery is payable separately. Services by other physicians are generally not included in the global fee for minor procedures.
For zero day post-operative period procedures, post-operative visits beyond the day of the procedure are not included in the payment amount for the surgery. Post-operative visits are separately billable and payable.
