The global surgical package is one of the most misunderstood reimbursement concepts in surgical billing. Surgeons and their billing teams routinely leave money on the table by not billing separately for services that fall outside the global package — and they equally risk audits by billing for services that should be included. The modifiers that break open the global package are worth knowing cold.
When a surgeon bills a surgical procedure code, Medicare and most commercial payers reimburse a single bundled payment — the global surgical package — that includes:
| Global Period | What It Covers | Example Procedures |
|---|---|---|
| 0-Day Global | Day of surgery only. No post-op visits included. | Minor skin procedures, simple biopsies, injections, endoscopies |
| 10-Day Global | Day of surgery plus 10 days post-op. All related visits included. | Excisions, minor orthopedic, skin flaps, hernia repair |
| 90-Day Global | Day before surgery through 90 days post-op. Pre-op day 1 visit + all related post-op visits included. | Major joint replacement, spinal fusion, open cardiac surgery, major abdominal procedures |
| XXX (no global) | No global period applies. Each service billed independently. | Radiology, most lab, pathology services |
| ZZZ (add-on codes) | Add-on codes — global period governed by primary procedure. | Add-on CPT codes only |
These modifiers are critical for surgical practices. They signal to payers that a service being billed during or around a global period is not included in the global package and should be paid separately.
Used to bill an E/M visit during the global period for a condition completely unrelated to the surgical procedure. The documentation must clearly establish a different diagnosis and reason for the visit.
Example: Patient is 30 days into a 90-day global period following knee replacement. They present for evaluation of a new shoulder injury from a fall. Bill the E/M with modifier 24.
Appended to an E/M code billed on the same day as a minor procedure (0-day or 10-day global). The E/M must be significant and separately identifiable — beyond the pre-service evaluation included in the procedure.
Example: Patient presents for removal of a skin lesion (10-day global). During the same visit, the physician conducts a complete evaluation of a new hypertension diagnosis. The E/M gets modifier 25.
Audit flag: Modifier 25 is one of the most OIG-scrutinized modifiers. Documentation must support that the E/M was truly distinct — not just a pre-procedure check. A separate chief complaint, history, and distinct medical decision making must be documented.
Appended to the E/M code when the physician makes the decision to perform a major surgery (90-day global) on the same day as the E/M or the day before. Without modifier 57, the E/M for a 90-day procedure would be bundled into the global package.
Example: Patient presents to orthopedic surgeon with acute hip fracture. Surgeon decides on same-day total hip replacement. The E/M gets modifier 57. The surgery gets its own code.
Used when a subsequent procedure during the global period was: (a) planned or anticipated at the time of the original procedure, (b) more extensive than the original procedure, or (c) for therapy following a diagnostic surgical procedure. This is distinct from modifier 79 — modifier 58 services are related to the original procedure.
Used when performing a surgical procedure during the global period that's completely unrelated to the original procedure. A new global period begins for the new procedure.
| Modifier | Service Type | Relationship to Original Procedure |
|---|---|---|
| 24 | E/M visit | Unrelated — different diagnosis |
| 25 | E/M visit | Same day as minor procedure — separately identifiable |
| 57 | E/M visit | Decision for major (90-day) surgery |
| 58 | Surgical procedure | Staged/related — planned or more extensive |
| 79 | Surgical procedure | Unrelated — completely different condition |
These services can be billed separately even within the global period:
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RCMAXIS surgical billing specialists audit global period modifier use, post-op visit capture, and return-to-OR coding for surgical practices across all specialties.
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