CMS Pub. 100-04, ch. 12, § 40.1

B3-4821, B3-15900.2

Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods

that apply to each surgical procedure. The payment rules for surgical procedures apply to

codes with entries of 000, 010, 090, and, sometimes, YYY.

Codes with “090” in Field 16 are major surgeries. Codes with “000” or “010” are either minor

surgical procedures or endoscopies.

Codes with “YYY” are A/B MAC (B)-priced codes, for which A/B MACs (B) determine the

global period (the global period for these codes will be 0, 10, or 90 days). Note that not all

A/B MAC (B)-priced codes have a “YYY” global surgical indicator; sometimes the global

period is specified.

While codes with “ZZZ” are surgical codes, they are add-on codes that are always billed with

another service. There is no postoperative work included in the fee schedule payment for the

“ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global

period assigned is applied to the primary code.

A. Components of a Global Surgical Package

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A/B MACs (B) apply the national definition of a global surgical package to all procedures with

the appropriate entry in Field 16 of the MFSDB.

The Medicare approved amount for these procedures includes payment for the following

services related to the surgery when furnished by the physician who performs the surgery. The

services included in the global surgical package may be furnished in any setting, e.g., in

hospitals, ASCs, physicians’ offices. Visits to a patient in an intensive care or critical care unit

are also included if made by the surgeon. However, critical care services (CPT codes 99291

and 99292) are payable separately in some situations. (See section 30.6.12.7 of this chapter for

further discussion of critical care visits unrelated to the procedure with a global surgical

period.)

• Preoperative Visits - Preoperative visits after the decision is made to operate beginning

with the day before the day of surgery for major procedures and the day of surgery for

minor procedures;

• Intra-operative Services - Intra-operative services that are normally a usual and

necessary part of a surgical procedure;

• Complications Following Surgery - All additional medical or surgical services required

of the surgeon during the postoperative period of the surgery because of complications

which do not require additional trips to the operating room;

• Postoperative Visits - Follow-up visits during the postoperative period of the surgery

that are related to recovery from the surgery;

• Postsurgical Pain Management - By the surgeon;

• Supplies - Except for those identified as exclusions; and

• Miscellaneous Services - Items such as dressing changes; local incisional 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.

B. Services Not Included in the Global Surgical Package

A/B MACs (B) do not include the services listed below in the payment amount for a procedure

with the appropriate indicator in Field 16 of the MFSDB. These services may be paid for

separately.

• The initial consultation or evaluation of the problem by the surgeon to determine the

need for surgery. Please note that this policy only applies to major surgical procedures.

The initial evaluation is always included in the allowance for a minor surgical

procedure;

• Services of other physicians 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 during the postoperative period which are not re-operations or treatment for complications. (A new postoperative 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. Examples of this are procedures to diagnose and treat epilepsy (codes

61533, 61534-61536, 61539, 61541, and 61543) which may be performed in succession

within 90 days of each other;

• Treatment for postoperative complications which requires 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;

• For certain services performed in a physician’s office, separate payment can no longer

be made for a surgical tray (code A4550). This code is now a Status B and is no longer

a separately payable service on or after January 1, 2002. However, splints and casting

supplies are payable separately under the reasonable charge payment methodology;

• Immunosuppressive therapy for organ transplants; and

• Critical care services (CPT codes 99291 and 99292) unrelated to the surgery, for

example, where a seriously injured or burned patient is critically ill and requires

constant attendance of the physician. See section 30.6.12.7 of this chapter for further

discussion of critical care visits unrelated to the procedure with a global surgical period.

C. Minor Surgeries and Endoscopies

Visits by the same physician on the same day as a minor surgery or endoscopy are included in

the payment for the procedure, unless a significant, separately identifiable service is also

performed. For example, a visit on the same day could be properly billed in addition to

suturing a scalp wound if a full neurological examination is made for a patient with head

trauma. Billing for a visit would not be appropriate if the physician only identified the need for

sutures and confirmed allergy and immunization status.

A postoperative period of 10 days applies to some minor surgeries. The postoperative period

for these procedures is indicated in Field 16 of the MFSDB. If the Field 16 entry is 010, A/B

MACs (B) do not allow separate payment for postoperative 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 not included in the global fee

for a minor procedures except as otherwise excluded. If the Field 16 entry is 000,

postoperative visits beyond the day of the procedure are not included in the payment amount

for the surgery. Separate payment is made in this instance.

See section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the

procedure with a global surgical period.

D. Physicians Furnishing Less Than the Full Global Package

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There are occasions when more than one physician provides services included in the global

surgical package. It may be the case that the physician who performs the surgical procedure

does not furnish the follow-up care. Payment for the postoperative, post-discharge care is split

between two or more physicians where the physicians agree on the transfer of care.

When more than one physician furnishes services that are included in the global surgical

package, the sum of the amount approved for all physicians may not exceed what would have

been paid if a single physician provides all services (except where stated policies, e.g., the

surgeon performs only the surgery and a physician other than the surgeon provides

preoperative and postoperative inpatient care, result in payment that is higher than the global

allowed amount).

Where a transfer of care does not occur, the services of another physician may either be paid

separately or denied for medical necessity reasons, depending on the circumstances of the case.

E. Determining the Duration of a Global Period

To determine the global period for major surgeries, A/B MACs (B) count 1 day immediately

before the day of surgery, the day of surgery, and the 90 days immediately following the day of

surgery.

EXAMPLE:

Date of surgery - January 5

Preoperative period - January 4

Last day of postoperative period - April 5

To determine the global period for minor procedures, A/B MACs (B) count the day of surgery

and the appropriate number of days immediately following the date of surgery.

EXAMPLE:

Procedure with 10 follow-up days:

Date of surgery - January 5

Last day of postoperative period - January 15