Why CPT Modifiers Matter in Global Surgery

Surgeons are no strangers to the complexities of billing, but one small detail that can make a big difference in reimbursement is the correct use of CPT modifiers for global surgery. If you’ve ever wondered why a claim was reduced or denied despite providing top-tier surgical care, the answer might lie in how the procedure was reported.

Whether it’s missing a necessary modifier or using the wrong one, even small mistakes can result in reduced payments, compliance risks, and extra administrative headaches. Global surgery packages simplify billing, but they also come with strict rules—especially when it comes to modifiers. Understanding when and how to use them ensures you get paid accurately for the services you provide. This is where medical billing outsourcing can make a real difference—ensuring accuracy, compliance, and maximized revenue without adding to your workload.

Comprehending the Medicare surgical package, its periods, and their impact on reimbursement is essential to understand the role of modifiers in global surgery.

The Global Surgical Package: What’s Included?

As defined by the Centers for Medicare & Medicaid Services (CMS), “the global surgical package, also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty.”

The surgical package varies by payer. According to CPT® Surgery Guidelines, it includes:

• E/M services on the day before and/or day of surgery (including history and physical)
• Local anesthesia (infiltration, metacarpal/metatarsal/digital block, or topical)
• Immediate postoperative care (operative notes, family/physician communication)
• Writing orders
• Post-anesthesia recovery evaluation
• Typical postoperative follow-up care

Medicare’s global surgery payment covers:

• Pre-operative visits: The day before or day of surgery for major procedures; the day of surgery for minor procedures.
• Intra-operative services: Standard components of the procedure.
• Post-operative care: Additional medical or surgical services for complications not requiring a return to the OR.
• Follow-up visits: Related to surgical recovery.
• Post-surgical pain management: Provided by the surgeon.
• Supplies: Except for specified exclusions.
• Miscellaneous services: Dressing changes, incision care, removal of sutures, drains, tubes, and splints, catheter insertion/removal, and tracheostomy tube changes.

Understanding which services are bundled within the global surgical package versus separately billable is crucial for accurate medical billing, ensuring proper reimbursement and preventing claim rejections or delays.

How the Global Period impacts Reimbursement and Role of Modifiers

Global periods (0, 10, or 90 days) in medical billing define the timeframe during which all related care associated with a surgical procedure is considered part of the surgical fee. The length of the global period determines the scope of services included in the surgical payment:

• 0-day global period: For minor procedures; same-day related E/M services are not separately billable.
• 10-day global period: Covers 10 days of post-op care; related E/M services are included in the procedure payment.
• 90-day global period: Includes one day of pre-op care and 90 days of post-op care in the procedure fee.

Modifiers come into play here. In surgical coding, modifiers are essential for conveying specific circumstances surrounding a procedure. They are used to reflect additional services or procedures performed during the global period, ensuring proper reimbursement. Modifier use depends on the nature of the service and the global period rule.

Modifiers help communicate details such as:

• Unrelated services provided during the global period
• When a procedure is significantly more challenging than usual
• To indicate distinct procedures performed at the same time
• If the patient needs a second surgery related to the first
• If follow-up surgery was anticipated

Using the right modifiers ensures accurate reimbursement, prevents claim denials, and maintains compliance with payer policies. Common mistakes in surgical modifier usage, such as omitting necessary modifiers or using them incorrectly, can result in denied claims, reduced payments, or improper bundling of services.

Key CPT Modifiers in Global Surgery and their Applications

• Modifier 22 (Increased Procedural Services): When a surgery is significantly more complex than usual

• Modifier 24 (Unrelated E/M During Post-Op Period): When follow-up care is unrelated to the original procedure

• Modifier 25 (Significant, Separate E/M on the Same Day as Surgery): Avoiding denials for pre-op evaluations

• Modifier 54 (Surgical Care Only): Used when one provider performs the surgery, while another handles pre- and/or post-op care. It indicates the surgeon is relinquishing all or part of post-op management.

• Modifier 57 (Decision for Surgery): Ensuring proper payment for E/M services that lead to major surgery

• Modifier 58 (Staged or Related Procedure during Post-Op Period): When additional planned procedures are needed

• Modifier 78 (Unplanned Return to the OR for Related Procedure): Capturing unexpected complications requiring surgery

• Modifier 79 (Unrelated Procedure During the Post-Op Period): When a new issue requires a separate surgical service

Reporting EM Services during the Global Period

Here’s an example of a scenario requiring the use of modifier 24 in cataract surgery with post-op treatment during the evaluation and management (E/M) visit:

A surgeon performs cataract surgery with intraocular lens implantation (CPT 66984), which has a 90-day global period. Two weeks after surgery, the patient develops an unrelated eye condition requiring an E/M visit. Since this visit is not related to the cataract surgery, it would typically be bundled under the global period unless indicated by a modifier.

Appending Modifier 24 (Unrelated E/M Service During Post-Op Period) to the E/M code allows for separate reimbursement, as the visit addresses a new issue not related to the surgical procedure.

Reporting non-EM Services during the Global Period

Non-E/M services performed during the global period must qualify for one of three applicable modifiers (modifier 58, modifier 78, and modifier 79) to be billed separately (aapc.com). For example, appending modifier 58 Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period indicates that the present procedure meets one (or more) of the following three conditions:

• The follow-up procedure was planned prospectively, or at the time of the initial procedure.
• The follow-up procedure is more extensive than the initial procedure. The follow-up procedure must be performed to treat the patient’s underlying condition, rather than due to a complication of the initial procedure.
• For therapy following a diagnostic surgical procedure.

The Cost of Incorrect Modifier Use in Surgical Coding

Improper use of modifiers in surgical coding leads to many problems. Using the wrong modifier (or omitting one) can create a financial and administrative headache. Here’s why:

• Denied or Reduced Payments: If modifiers aren’t applied correctly, insurers may see the procedure as improperly billed or not medically necessary. This can lead to outright claim denials or lower payments than expected, forcing you to fight for the reimbursement you deserve.

• Compliance Risks and Audits: Incorrect modifier use can raise red flags with payers, increasing the risk of audits. In worst-case scenarios, it could lead to penalties, repayments, or even jeopardizing your provider status with insurance networks.

• Payment Delays and Extra Admin Work: Modifier mistakes mean claims get stuck in limbo, dragging out payment cycles. Resubmitting claims and managing denials puts extra strain on your staff, taking time away from patient care.

Ensure Clear Documentation to Support Modifier Use

Clear and thorough documentation is essential to justify the use of modifiers in surgical coding. Records should detail the patient’s condition, the medical necessity of the procedure, and any unique circumstances that warrant modifier application. This includes notes on preoperative assessments, intraoperative findings, and postoperative care. Comprehensive documentation not only supports the rationale for using specific modifiers but also strengthens the claim’s validity, reducing the risk of denials and ensuring timely reimbursement.

For example, for appending CPT modifier 22, Unusual Procedural Services, Medicare Administrative Contractor (MAC) Palmetto GBA mandates that additional documentation is required for modifier 22 reimbursement, such as an operative report and a concise statement specifying how the service differs from the usual. This information must be in the appropriate documentation record or sent as separate documentation for electronic claims. If paper claims are submitted, the information must be on an attachment to the CMS-1500 claim form.

Palmetto GBA clarifies: “Failure to submit the documentation appropriately may result in payment for the surgical code only, based on the Medicare Physician Fee Schedule Database (MPFSD).”

By maintaining meticulous records, healthcare providers can enhance compliance and safeguard against denials and audits.

Get Paid What You Deserve with Expert Support

While surgery is your expertise, coding aspects can impact your bottom line. Proper use of CPT modifiers in global surgery not only ensures compliance but also helps you receive full and fair reimbursement for your work. Partnering with a knowledgeable provider of healthcare revenue cycle management solutions can make all the difference.

Expert coders in medical billing outsourcing companies have a comprehensive understanding of current surgical coding guidelines, modifier definitions, and payer-specific requirements, enabling them to choose the appropriate modifiers for various procedures. Partnering with experts can help you minimize denials and maximize revenue, so that you to focus on what you do best: surgery.