A surgical practice sees the patient back at day 12, bills an office visit, and the claim comes back as part of the operation. The surgery, the visit before it and the routine follow-up sit inside one payment, and the window is set by the procedure code. Knowing where that window ends decides whether the visit pays or becomes free work.
What this covers
- The package bundles the operation, the pre-operative visit after the decision to operate, routine follow-up and complications that stay out of the operating room.
- Medicare assigns each procedure an indicator: 000 for endoscopies and some minor procedures, 010 for other minor procedures, 090 for major surgery.
- A 10-day package runs 11 days. A 90-day package runs 92 days, from the day before surgery.
- Modifier 25 unbundles a same-day E/M with a minor procedure. Modifier 24 bills an unrelated E/M inside a post-operative period, and 54 and 55 split a package between two practices.
One operation, one payment, until the global period runs out.Inside that window the work is the surgeon’s unless a modifier says otherwise.
Medicare built the global surgical package so a contractor in one state and a contractor in another would pay the same services the same way. The package is a payment rule, not a clinical one. A visit that feels separate to the practice can still sit inside the surgical fee, and a routine-looking visit can fall outside it when the patient’s problem has nothing to do with the operation.
The three global periods and how the clock runs
Medicare pays for an operation and the care around it as one amount. The global surgical package covers the services a provider normally furnishes before, during and after a procedure, and providers in the same group practice with the same specialty bill as a single physician.
The length of the package comes from the procedure code. The Medicare Physician Fee Schedule assigns every procedure a global surgery indicator: 000 for endoscopies and some minor procedures, 010 for other minor procedures, and 090 for major surgery. The table below lists the rest.
| Indicator | What it covers | Window |
|---|---|---|
| 000 | Endoscopies and some minor procedures | Procedure day only |
| 010 | Other minor procedures | Procedure day plus 10 days, 11 in all |
| 090 | Major surgery | Day before surgery, day of surgery and 90 days after, 92 in all |
| XXX | No global concept applies | No package to break, so no modifier |
| YYY | Contractor-priced codes | The MAC sets 0, 10 or 90 days |
| ZZZ | Add-on codes | Follows the primary procedure |
| MMM | Maternity codes | The usual global period does not apply |
The arithmetic is easy to get wrong. A 10-day package is 11 days long, the procedure day plus the 10 days after it. A 90-day package is 92 days long. A 000 package has no post-operative days, so a visit after the procedure day bills separately.
Open the Medicare Physician Fee Schedule Look-Up Tool, select Global under Modifier, and read the column for the code. A wrong indicator makes every later decision wrong, so a medical coding and billing review starts here.
What the package pays for, and what it leaves out
The package is generous about what it swallows. When the surgeon furnishes the service, these sit inside the payment:
- Pre-operative visits after the decision to operate, back to the day before surgery for a major procedure
- Intra-operative services that are a normal part of the operation
- Follow-up visits during the recovery period and post-surgical pain management
- Supplies, dressing changes and local incision care
- Removal of sutures, staples, lines, tubes, drains, casts and splints
- Complications the surgeon treats during the period when they stay out of the operating room
Medicare excludes a defined set of services. These bill separately:
- The surgeon’s first evaluation that finds the need for major surgery, reported with modifier 57
- Another provider’s related services, unless the surgeon and that provider agree on a transfer of care
- Visits unrelated to the surgical diagnosis, unless a complication caused them
- Treatment of an underlying condition or an added course of treatment outside normal recovery
- Diagnostic tests and procedures, including diagnostic radiology
- A complication that requires a return to the operating room
A complication the surgeon manages in the office or on the ward is post-operative care and cannot bill separately. The same complication that requires a return to the operating room is not. Control of post-operative hemorrhage stays bundled unless the patient goes back, and then it bills with modifier 78.
Minor and major procedures: two different same-day rules
The rules diverge at the same-day visit. A procedure with a global period of 000 or 010 days is a minor surgical procedure, and an E/M on the same date is generally included in the payment, new patient or established.
Modifier 25 is the way out. It goes on the E/M code, never the procedure code, and asserts that the E/M was significant and separately identifiable. Different diagnoses are not required.
A 090-day procedure is a major surgical procedure, and the pre-operative rule runs the other way. The E/M that produced the decision to operate bills with modifier 57 on the day of surgery or the day before. Every other pre-operative E/M that day is bundled.
Modifier 57 has no place with a minor procedure. Medicare instructs that MACs may not pay it on the day of, or the day before, a 000 or 010 procedure.
- Pull the global indicator before the encounter is coded
- For 000 and 010 codes, treat the same-day visit as part of the procedure unless the E/M work was significant and separately identifiable
- Put modifier 25 on the E/M line only, never on the procedure line
- For a 090 code where the visit produced the decision to operate, put modifier 57 on the E/M line
The modifiers that legitimately break the package
Six modifiers carry the label global surgery in the NCCI policy manual: 24, 25, 57, 58, 78 and 79. They may also bypass an NCCI procedure-to-procedure edit when the clinical circumstances justify it.
| Modifier | What it means | When it applies | What it changes |
|---|---|---|---|
| 24 | Unrelated E/M during a post-operative period | A visit inside a running period for a problem with no link to the surgery | Pays the E/M, and the record has to show the problem is unrelated |
| 25 | Significant, separately identifiable E/M the same day as a procedure | A 000 or 010 procedure, or an XXX procedure, plus an E/M | Pays the E/M in addition to the procedure fee |
| 57 | Decision for surgery | A 090 procedure, where the visit on the day of or the day before produced the decision to operate | Pays that one E/M. Other pre-operative visits stay bundled |
| 58 | Staged or related procedure during the period | A second procedure that was planned, is more extensive, or follows a diagnostic one | Pays the second procedure and starts a new period |
| 78 | Unplanned return to the operating room | A complication that needs a return to the operating room | Pays the intra-operative value of the return procedure |
| 79 | Unrelated procedure during the period | A different operation on an unrelated problem inside the window | Pays the second procedure and starts a new period |
Modifier 24 is the one most often missing. When a visit inside a running post-operative period has nothing to do with the surgery, the E/M code needs 24 or the line denies as part of the global fee. Documentation must support that the service is unrelated to the post-operative care. An infection in the surgical wound is post-operative care, not an unrelated problem.
Modifier 24 and modifier 25 can appear on one claim. Medicare’s global surgery booklet describes the case: a significant, separately identifiable E/M on the day of a procedure that also falls inside the post-operative period of another, unrelated procedure carries both modifiers on the E/M line. Medical coding teams see this where one provider operates and runs a primary care panel.
Transfer of care: 54, 55 and one package divided
A 10-day or 90-day package can be divided. When the surgeon will not provide the follow-up care, the surgeon bills the procedure code with modifier 54 and the provider who takes over bills the same code, on the same date of service, with modifier 55. The date of service is the date of the operation, and general surgery billing teams report the date care changed hands in the claim’s remarks field.
| Modifier | Who bills it | What it pays |
|---|---|---|
| 54 | The operating surgeon who gives up the follow-up | The pre-operative and intra-operative shares combined, plus any post-operative days the surgeon keeps |
| 55 | The provider who takes over the post-operative care | The post-operative share, divided by the days each provider covered |
| 56 | A provider who did only the pre-operative work | The pre-operative share. Rare, and usually folded into the surgeon’s 54 |
The transfer needs a paper trail. Both providers keep a copy of the written transfer agreement in the patient’s medical record, and the receiving provider must furnish at least one service before billing the post-operative care. Without a transfer, another provider’s occasional post-discharge services bill with no modifier.
The money divides by percentage and by days. The fee schedule carries separate pre-operative, intra-operative and post-operative shares for each code, and modifier 54 pays the pre-operative and intra-operative shares combined. Where more than one provider bills the post-operative care, the MAC divides that allowance by the number of post-operative days and multiplies by the days each provider covered. The manual’s example takes a 17 percent post-operative share on a 90-day package and pays 11.3 percent for 60 days and 5.7 percent for 30.
Split care does not apply to a 0-day package, because there are no post-operative days to divide. Modifier 54 also does not apply to assistant-at-surgery services or to an ambulatory surgical center’s facility fees.
Two rules changed for 2025. Modifier 54 is now required whenever the surgeon does not intend to provide the post-operative care, including an informal transfer that is expected but never documented. CMS also added add-on code G0559 for the practitioner who furnishes a post-operative visit during a 90-day period, did not perform the operation and is not in the same group practice as the surgeon.
Providers in one group practice with one specialty bill and accept payment as a single physician, so the package does not split inside that group. A practitioner in the same specialty but a different group may bill G0559 when that practitioner furnishes the post-operative care.
Where these claims go wrong, and the order to work in
Most global-period denials are modifier choices that do not match the timeline, or notes that never establish that the visit stood apart from the operation.
Note whether the code is 000, 010, 090, XXX, YYY or ZZZ. That value sets everything else.
Mark the first and last day. A 090 window opens the day before surgery, a 010 window on the procedure day.
Decide whether the visit is recovery, a complication, or a new problem. Recovery and complications that stay out of the operating room are inside the fee.
25 for a same-day E/M with a minor procedure, 57 for the decision to operate on a major one, 24 for an unrelated visit inside the window, and 58, 78 or 79 for a second procedure.
The note has to stand on its own as an E/M service, or as a visit unrelated to the operation, without leaning on a second diagnosis code.
Read the payer’s own policy before assuming the Medicare window applies to that plan.
Many commercial plans adopt the CMS global days indicator and the same 0, 10 and 90-day windows. Others publish their own policy with their own exclusions and their own handling of modifier 24 and 25 claims, and a YYY indicator leaves the period to the payer. Read the policy for the plan that is paying, and treat the Medicare rules as a baseline.
Medicare requires practices with 10 or more practitioners in nine states to report post-operative E/M visits with 99024, a no-pay code, for a published list of high-volume procedures. The nine states are Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon and Rhode Island.
Global surgical package questions
The window follows the procedure code, not the diagnosis. A 000 code bundles only the day of the procedure. A 010 code runs 11 days, counting the procedure day and the 10 days after it. A 090 code runs 92 days, counting the day before surgery, the day of surgery and the 90 days that follow.
Only when the visit is unrelated to the surgery. Report the E/M code with modifier 24 and make the note show that the problem has no link to the operation or to its complications. A visit for recovery, for wound care, or for a complication managed outside the operating room stays inside the surgical fee.
Modifier 25 belongs on an E/M billed the same day as a minor procedure or an endoscopy, when the E/M work was significant and separately identifiable from the procedure. Modifier 24 belongs on an E/M that falls inside the post-operative period of another procedure and is unrelated to it.
No. Modifier 57 identifies the visit that produced the decision to operate on a major procedure, on the day of or the day before surgery. Medicare states that MACs may not pay an E/M billed with modifier 57 on the day of or the day before a procedure with a 000 or 010 global period.
The surgeon bills the procedure code with modifier 54 and the provider who takes over follow-up bills the same code, on the same date of service, with modifier 55. Both charts keep a copy of the written transfer agreement, the claim shows the date care changed hands, and the receiving provider furnishes at least one service before billing.
Many commercial plans adopt the CMS global days indicator and the same 0, 10 and 90-day windows, and some publish their own policy with different exclusions or different handling of modifier 24 and 25 claims. Codes with a YYY indicator leave the length of the period to the payer.
The bottom line
The global period is a payment window that opens and closes on dates set by the procedure code, not by the visit. Work inside it is the surgeon’s work unless a modifier says otherwise: 25 for a same-day E/M with a minor procedure, 57 for the decision to operate on a major one, 24 for an unrelated visit, and 58, 78 or 79 for a second procedure. When follow-up moves to another practice, the same code and the same date of service go out twice, once with 54 and once with 55.
How much surgical follow-up is going unbilled?
We code and bill surgical practices, including the global-period decisions that decide whether a post-operative visit pays or disappears into the surgical fee. Send us one month of operative reports and the claims that came out of them, and we will show you where the package was misread in both directions.
Request a free surgical coding auditThis article describes general coding and billing practice rather than a coverage determination; confirm the global period and modifier requirements with each payer’s policy and provider manual.
