Direct Answer
The surgical global period is the period during which Medicare considers all related services to be included in the payment for a surgical procedure — no separate billing is allowed for routine pre- and post-operative care related to the surgery during this period. Understanding what is and isn't included in the global period, and using the correct modifier when separate billing is genuinely warranted, is one of the most frequently misapplied concepts in surgical billing — resulting in both compliance violations (billing global-included services separately) and revenue loss (not billing separately when separate billing is appropriate).
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Global Period Types
CMS assigns one of three global period types to each surgical procedure code: 0-day global (no post-operative period — the surgery fee covers the day of surgery only; any E&M services the following day or after are separately billable); 10-day global (the surgical fee includes the day before surgery, the day of surgery, and 10 days after — approximately 12 total days); and 90-day global (the surgical fee includes the day before surgery, the day of surgery, and 90 days after — approximately 92 total days). Most major surgery codes (orthopedics, spine, cardiac, general surgery) carry 90-day global periods. Many minor procedures (injections, minor skin surgery, endoscopy, many office procedures) carry 0-day or 10-day global periods. The global period assignment for each CPT code is published in the Medicare Physician Fee Schedule (MPFS) database and is determined by CMS based on the typical post-operative care included in that surgery.
What Is Included in the Global Period
Within the global period, the following are included in the surgical payment and may not be separately billed: the pre-operative visit on the day before a major surgery; all intraoperative services (including care by the operating surgeon during the procedure); immediate post-operative care (including writing post-op orders, dictating the operative report); post-operative visits related to normal recovery from the surgery (e.g., wound checks, suture removal, cast changes for a fracture); and post-operative pain management where the surgeon provides the service. Services related to the surgical condition — managing the condition that was operated on through the normal recovery — are included. What this means practically: if a patient presents for a routine post-op visit at 2 weeks after knee replacement, the orthopedic surgeon cannot bill separately for that visit — it is included in the knee replacement global period payment.
Services That Are Separately Billable
Several categories of services are separately billable even during a global period: visits for problems clearly unrelated to the surgery (a hypertension follow-up during the 90-day post-op period after cholecystectomy — not related to the surgery); treatment of complications that require a return to the operating room (separately billable with Modifier 78); services that go beyond normal post-operative care for the condition (e.g., physical therapy, which is not typically part of the surgeon's global period services); diagnostic tests ordered by the surgeon that are not interpretive services (lab orders, imaging orders — the tests themselves are billed by the lab/radiology); and E&M services that are clearly documented as addressing a different, unrelated medical problem. The documentation must clearly establish that the separately billed service is unrelated to the surgical condition or falls outside the global period's scope.
Global Period Modifiers
The key global period modifiers: Modifier 24 (unrelated E&M during post-operative period) — used when a surgeon bills an E&M visit during the global period for a problem unrelated to the surgery; Modifier 25 (significant, separately identifiable E&M, same day as minor procedure) — used for the pre-procedure E&M when a 0 or 10 global procedure is performed; Modifier 57 (decision for surgery) — used for the E&M visit that leads to the decision to perform a major (90-day global) surgery, which occurs on the day of or the day before the surgery; Modifier 58 (staged or related procedure during post-op period) — planned staged procedures performed during the global period; Modifier 78 (return to OR for related procedure) — unplanned return to the operating room for a complication during the global period; Modifier 79 (unrelated procedure during post-op period) — a separate unrelated surgical procedure performed during the global period.
Split Global and Transfer of Care
When surgical care is split between providers — one surgeon performs the pre-operative evaluation and the operation, and a different physician (or covering physician) provides all the post-operative care — the global fee can be split using Modifier 54 and Modifier 55. Modifier 54 (surgical care only) is appended by the surgeon who performed the operation — indicating they are billing only for the surgical procedure itself, not the post-operative care. Modifier 55 (post-operative management only) is appended by the physician providing the post-operative care — indicating they are billing only for the 90-day post-operative management portion of the global fee. The split must be formally documented — the transfer of care should be documented in the medical record and communicated between providers. CMS will not pay for the combined total of Modifiers 54 + 55 to exceed 100% of the global fee.
FAQ
What happens if a patient sees a different surgeon during the original surgeon's global period?
If a patient sees a different physician during the original surgeon's global period (e.g., a covering physician during the surgeon's absence, or the patient changes surgeons), the covering or substitute physician bills using Modifier 55 (post-operative management only) for the visits they provide during the global period, with payment allocated from the global surgical fee. The original surgeon's billing should be adjusted to use Modifier 54 (surgical care only) to indicate they are not providing post-operative care. If the second physician sees the patient for a completely unrelated problem — not post-operative follow-up — they may bill an E&M with Modifier 24 rather than the Modifier 55 global period post-op code. The specific scenario matters for correct modifier assignment — covering physicians in surgical practices should be trained on global period billing rules to avoid incorrectly billing full E&M rates for post-operative visits they provide for the original surgeon's global period.
Are emergency department visits during the global period separately billable?
An emergency department visit by a patient during the surgeon's global period is generally not separately billable by the surgeon if the ED visit is for the surgical condition or a complication of the surgery. If the patient presents to the ED with a post-surgical complication (wound dehiscence, infection, pulmonary embolism following surgery), and the treating surgeon is consulted or sees the patient in the ED, that service is included in the global period and not separately billable. However, the hospital's ED facility fee and the ED physician's professional fee are billed separately by those providers — the global period applies only to the operating surgeon's professional services, not to other providers or the facility. If the patient presents to the ED for a problem clearly unrelated to the surgery, the surgeon's services at that ED visit can be billed with Modifier 24.
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