Description

Reimbursement for surgical procedures includes payment for all related services and supplies that are routine and necessary for performing the procedure and recovery. Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. Reimbursement for these services is based on a global allowance. Claims for services considered to be directly related to pre-procedure, intra-procedure, and post-procedure work are included in the global reimbursement and will not be paid separately.

Blue Cross Blue Shield North Carolina (Blue Cross NC) enforces pre- and post-operative global days based on, but not limited to, CMS standards. The global period is defined as the period of time during which claims for services related to the primary procedure will be denied as an unbundled component of the total surgical package. Major procedures have a global period of 90 days. Minor procedures have a global period of 10 or 0 days.

The global period includes Evaluation and Management (E/M) services that are related to the procedure. Payment for related medical or surgical services performed the day prior to, the day of, or within 90 days after a major surgical procedure is included in global allowance. Payment for related medical or surgical services performed the same day as a minor surgical procedure, as well as medical or surgical services performed within 10 days after a 10 day procedure, is included in the global allowance. Zero (0) day minor surgical procedures include related medical or surgical services performed the same day as the procedure, but do not include related medical or surgical services performed after the procedure in global surgical bundling. Global surgery guidelines apply to both professional and facility claims and apply to the primary surgeon and co-surgeon. 

Claims may be processed according to same group practice or same provider ID. Same group practice is defined as a physician and/or other qualified health care professional of the same group and same specialty with the same Federal Tax ID number.

Policy

Blue Cross NC will reimburse services or supplies billed during the global period according to the criteria outlined in this policy.

Services or supplies Blue Cross NC considers to be mutually exclusive, incidental to, integral to, or within the global period of the primary service rendered are not eligible for reimbursement.

Reimbursement Guidelines

The following will be bundled into the surgical package and will not be eligible for separate reimbursement when billed during the applicable global day period of 0, 10, or 90 days. Certain services included herein may be eligible for additional reimbursement outside of the global package when appended with ce rtain modifiers.

Major Surgery- 90-day global period:

• Related E&M services performed the day prior or the same day to a 90-day procedure 
• Related E&M services performed within 90 postoperative days of a 90-day procedure
• Preventive and preventive-like visits performed the day prior or the same day to a 90-day procedure. 
• Care management and transitional care services performed within 90 postoperative days of a 90-day procedure
• Any additional medical or surgical services provided within 90 postoperative due to complications of the original major surgery 
• All anesthesia and anesthetic services performed by the surgeon 
• Post operative pain management, including epidural management or subarachnoid drug administration
• All related supplies (See also Bundling Guidelines) 

Minor Surgery- 10-day global period:

• Related E&M services performed the same day to a 10-day procedure 
• Related E&M services performed within 10 postoperative days of a 10-day procedure 
• Preventive and preventive-like visits performed the day prior to the same day of a 10-day procedure
• Care management and transitional care services performed within 10 postoperative days of a 10-day procedure
• Any additional medical or surgical services provided within 10 postoperative days due to complications of the original minor surgery
• All anesthesia and anesthetic services performed by the surgeon
• Post operative pain management, including epidural management or subarachnoid drug administration 
• All related supplies (See also Bundling Guidelines) 

Minor Surgery- 0-day global period:

• Related E&M services performed the same day to a 0-day procedure 
• Preventive and preventive-like visits performed the day prior to the same day of a 0-day procedure 
• All anesthesia and anesthetic services performed by the surgeon 
• Post operative pain management, including epidural management or subarachnoid drug administration 
• All related supplies (See also Bundling Guidelines) 

Modifier Use During the Global Period Days: 

• Modifier 24 signifies an unrelated Evaluation and Management (E/M) service during a postoperative period. Documentation must support the use of this modifier in the global period in order for a service to be eligible for reimbursement.  
• Modifier 25 represents a significant and separately identifiable E&M service on the same day of a procedure or other service. Documentation must support the use of this modifier and provide the necessary detail in order for a service to be eligible for reimbursement.
• Modifier 57 indicates that the decision for surgery occurred during an E&M encounter. It is not used with minor surgeries. E&M services appended with Modifier 57 are only eligible for reimbursement if they represent the initial decision for surgery. Any E&M service performed the day before or the day of a major surgery but also appended with Modifier 57 requires evidence that the decision for surgery was completed at that time and had not been previously planned. Additionally, it is inappropriate for providers to bill Modifier 57 if the decision for surgery occurred at a previous E&M service. In that scenario, the E&M service, even though appended with Modifier 57, will not be eligible for reimbursement. 
• Staged Procedures should be appended with Modifier 58. Unplanned returns to the operating room for a related procedure during the postoperative period should be appended with Modifier 78. Likewise, unrelated procedures that are performed during the global surgical period should be appended with Modifier 79. When appending procedures with Modifier 58, 78, or 79 during a 90 day or 10 day postoperative period of a previous major or minor surgery, there must be sufficient documentation supporting the use of one of the aforementioned modifiers for that procedure to be eligible for reimbursement outside of the global surgical package. 
• Procedures billed in an office setting during a global period with the same procedure code will be understood to represent postoperative care and will be subject to global reimbursement rules.
• Repeat surgical procedure(s) by the same surgeon performed on the same day as the original surgery, requiring a return trip to the operating room should be appended with Modifier 76. Documentation must support the use of this modifier and provide the necessary detail in order for a service to be eligible for reimbursement.
• Repeat surgical procedure(s) by a different surgeon, on the same day as the original surgery, requiring a return trip to the operating room should be appended with Modifier 77. Documentation must support the use of this modifier and provide the necessary detail in order for a service to be eligible for reimbursement.
• Non-physician practitioners (NPP) are only eligible for reimbursement of a Major Procedure (90 day) when submitted with an assistant modifier. 

Rationale

Consistent with CMS and industry standard best practices, Blue Cross NC’s global payment for surgical procedures is inclusive of all related services. Blue Cross will consider additional reimbursement for unrelated services consistent with the content of this policy. 

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com .

Related policy

Bundling Guidelines

Modifier Guidelines

Split Surgical Package

Unplanned Return to Surgery

References

American Medical Association, Current Procedural Terminology (CPT ^®)

Centers for Medicare & Medicaid Services, CMS Manual System, Medicare Claims Processing Manual

100-04 100-04 | CMS

CMS MLN Global Surgery Booklet (cms.gov)

History

6/1/2022 New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/2022 Routine policy review. Minor revisions only. (ckb)

9/28/2023 Non-physician practitioners reimbursement of a Major Procedure (90 day) language added to Reimbursement Guidelines. Medical Director approved. Notification on 7/18/2023 for effective date 9/28/2023. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.

Legal

Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benef its are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.

BLUE CROSS^®, BLUE SHIELD^® and the Cross and Shield symbols are marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and trade names are the property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.