Global Periods Explained — Without the Confusion

What's included, what isn't, and when you can actually bill.

Few words cause more confusion in a surgical practice than: "The patient is in the global period."

For some billing teams, that sentence immediately means don't bill anything. For others, it means adding a modifier and hoping the payer processes the claim.

Neither approach is correct.

A global period does not mean every service provided to a patient after surgery is free. But it also doesn't mean every additional service is separately billable.

The real question is much simpler: What service was provided, why was it necessary, and is that service already included in the payment for the surgery?

Once you understand that, global periods become much less confusing.

First: What Is a Global Surgical Package?

When a payer reimburses a physician for many surgical procedures, that payment isn't necessarily just for the procedure performed in the operating room. It may also include certain services normally associated with the procedure before and after surgery.

Think of it as a package of related services. Under Medicare's global surgery rules, procedures generally fall into categories that include:

0-day global — the global period generally includes the day of the procedure.
10-day global — the global period includes the procedure day and the following 10 days.
90-day global — major procedures generally include one day of preoperative services and 90 days of postoperative care, subject to Medicare's global surgery rules.

Commercial payer policies can differ, so Medicare's rules should never automatically be assumed to apply to every plan.

What Is Actually Included?

This is where practices sometimes make global periods more complicated than they need to be.

Ask yourself: Would this service normally be considered part of taking care of the patient after this surgery?

If yes, there is a good chance it is included in the global package. Examples can include:

Routine postoperative visits
Normal wound checks
Routine dressing changes
Suture or staple removal
Routine postoperative pain management
Discussion of normal recovery
Standard activity restrictions
Typical postoperative follow-up
Services related to normal healing

You don't separately bill an office visit simply because the physician examined the patient. That postoperative work may already have been accounted for in the surgical payment.

The Mistake: "Everything for 90 Days Is Included"

This is probably the biggest misunderstanding surrounding global periods.

Imagine an orthopedic surgeon performs a total knee replacement. Thirty days later, that same patient falls and fractures their wrist. The patient is technically still in the global period for the knee surgery.

But was evaluation and treatment of the wrist fracture included in the reimbursement for the knee replacement?

No.

The global period follows the surgical service and related care. It doesn't turn the patient into a non-billable patient for 90 days. That distinction is critical.

The Other Mistake: "It's Different, So Add a Modifier"

Modifiers aren't tools for getting around payer edits. They're used to accurately explain the circumstances surrounding a service.

Before adding a modifier, you need to understand what actually happened. Several modifiers become particularly important during global periods.

Modifier 24: An Unrelated E/M Service

Modifier 24 may be appropriate when the same physician or qualified healthcare professional provides an unrelated E/M service during the postoperative period.

For example: a general surgeon performs a hernia repair. Several weeks later, the patient returns for evaluation of an unrelated breast mass. The patient is still within the global period of the hernia repair, but the breast evaluation isn't routine postoperative care.

When supported by the documentation, the E/M service may be separately reportable with Modifier 24. The key word is unrelated.

Modifier 58: Staged, Related, or More Extensive Procedures

Modifier 58 may be appropriate when a procedure during the postoperative period is:

Planned or staged prospectively,
More extensive than the original procedure, or
Therapy following a diagnostic surgical procedure,

when the applicable coding requirements are met.

This is not simply a "second surgery" modifier. The circumstances have to support its use. An important distinction is that a qualifying procedure reported with Modifier 58 generally begins a new postoperative period.

Modifier 78: An Unplanned Return for a Related Procedure

Modifier 78 addresses certain situations in which the patient must return to an operating or procedure room for an unplanned, related procedure during the postoperative period.

For example, a patient experiences a postoperative complication requiring an unplanned return to the operating room.

This is different from routine postoperative management and different from a staged procedure. Modifier 78 also has different reimbursement and global-period implications than Modifier 58.

Modifier 79: An Unrelated Procedure

Modifier 79 may be appropriate when the same physician performs an unrelated procedure or service during another procedure's postoperative period.

Think about our orthopedic patient again. The patient is recovering from knee surgery but subsequently sustains an unrelated wrist fracture requiring surgery by the same physician. The second surgery may be separately reportable with Modifier 79 when the requirements are met.

A new global period generally begins with the unrelated procedure.

And Don't Forget Modifier 57

The patient may also require an E/M encounter that results in the decision to perform major surgery. That's where Modifier 57 can become important.

For major surgery, the decision-for-surgery E/M service may be separately reportable when appropriately documented. This becomes especially important when a patient is evaluated immediately before an urgent or emergent surgery.

The E/M that led to the decision for surgery is not necessarily the same thing as routine preoperative care already included in the surgical package.

What About Complications?

This is where global surgery gets particularly confusing.

Practices sometimes assume: "It's a complication, so we can bill it." Not necessarily.

Others assume: "It's related to surgery, so we can never bill anything." Also not necessarily.

Under Medicare rules, treatment of postoperative complications that does not require a return to the operating or procedure room is generally included in the global surgical package. If the complication requires an unplanned return to an operating or procedure room, separate reporting may be possible depending on the circumstances.

This is an area where the actual service, location, documentation, procedure performed, and payer policy need to be reviewed carefully.

What About Diagnostic Tests?

Another misconception is that everything ordered during a global period is bundled.

Diagnostic testing isn't automatically included simply because the patient is postoperative. Depending on the circumstances and payer rules, services such as imaging or other diagnostic tests may be separately reportable.

Again, the answer isn't found simply by looking at the calendar. You have to look at the service.

A Simple Way to Think About Global Periods

When reviewing an encounter, work through these questions:

Is the patient currently within a global period? If no, normal coding rules apply. If yes, keep going.
Why is the patient being seen? Is this routine recovery or something else?
Is today's service related to the original procedure? If unrelated, separate reporting may be possible.
Is another procedure being performed? Determine whether it is staged, related, unplanned, or completely unrelated.
Does a modifier accurately describe the situation? Possibilities may include 24, 57, 58, 78, or 79 depending on the circumstances.
Does the documentation support that modifier? This is where everything comes together.

Stop Using "Post-Op" as the Diagnosis for Every Encounter

One workflow issue can quietly cost surgical practices significant revenue.

The patient walks through the door during the global period and someone immediately labels the encounter POST-OP.

But what if the patient isn't actually there for postoperative care? Maybe they have a new injury. Maybe they're being evaluated for another condition. Maybe the physician is making a decision about another surgery.

The patient's status and the reason for today's encounter aren't necessarily the same thing. Your scheduling, documentation, coding, and billing processes should recognize the difference.

Documentation Needs to Make the Distinction Clear

If you expect a payer to reimburse a service separately during the global period, your documentation should make the circumstances clear. Don't make the payer — or your coder — piece together the story.

Clearly document:

Why the patient is being seen
Whether the problem is related or unrelated to the previous surgery
The condition evaluated
Medical decision making
Treatment provided
Whether another procedure is planned
Why additional intervention was necessary

The modifier should tell the payer what happened. The documentation should prove it.

Practice Owners: Audit Your "No-Charge" Encounters

Here's an exercise worth doing.

Pull your practice's no-charge encounters occurring during 90-day global periods for the last 90 days. Don't start with claims — start with the medical records. Review why those patients were actually seen.

How many were truly routine postoperative visits? And how many involved:

New conditions?
New injuries?
Unrelated problems?
Additional procedures?
Decisions for additional surgery?
Diagnostic services?

If every encounter was automatically categorized as postoperative simply because the patient was inside a global period, you may uncover a revenue leakage problem that has been hiding in plain sight.

The Bottom Line

Global periods don't have to be complicated.

Stop asking: "Is the patient in a global period?" That's only the first question.

Instead, ask: "What are we treating today, and was that service already included in the original surgery?"

Routine postoperative care? Usually included.
Unrelated E/M service? May be separately billable.
Staged or more extensive procedure? Review Modifier 58.
Unplanned return for a related procedure? Review Modifier 78.
Unrelated procedure? Review Modifier 79.
Decision for major surgery? Review Modifier 57.

The global period isn't a 10- or 90-day "do not bill" window. It's a defined package of services related to a surgical procedure.

And understanding that difference is how practices protect both their revenue and their compliance.