Global Surgical Package: CMS 0, 10, and 90-Day Global Periods, Modifiers, Teaching Physician Rules, and Split/Shared Visits

The global surgical package (also called global surgery rules) is a bundled reimbursement methodology under the Centers for Medicare & Medicaid Services (CMS) Medicare Physician Fee Schedule (MPFS) that combines a surgical procedure and its routine preoperative, intraoperative, and postoperative Evaluation and Management (E/M) services into a single global payment. Codified in the Medicare Claims Processing Manual, Chapter 12, Section 40, the global surgical package prevents duplicate unbundling of routine periprocedural visits while defining strict CPT modifier pathways—such as Modifier 24, Modifier 57, Modifier 58, Modifier 78, and Modifier 79—when a patient requires distinct, staged, or complication-driven care.

What Is the Global Surgical Package?

Under the Medicare Physician Fee Schedule National Physician Fee Schedule Relative Value File, every CPT surgical and procedural code is assigned a three-character Global Surgery Indicator. When a surgeon—or any physician within the same group practice and same specialty (who are treated by Medicare claims processors as a single billing physician)—reports a procedure with a 0-day, 10-day, or 90-day global period, the single CPT fee schedule payment covers a standardized bundle of clinical services:

• Preoperative Visits: Preoperative E/M visits performed after the decision to operate has been made, beginning the day before surgery for major procedures (090) or on the day of surgery for minor procedures (000 and 010).
• Intraoperative Services: All surgical work that is a usual and necessary part of the primary procedure, plus local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia when administered by the operating surgeon.
• Postoperative Visits and Routine Complications: All hospital, intensive care, office, or telehealth follow-up visits by the surgeon related to recovery from the surgery during the designated postoperative window (0, 10, or 90 days), including dressing changes, local incision care, removal of sutures/staples/drains/casts, insertion/removal of urinary catheters and nasogastric tubes, postoperative pain management by the surgeon, and medical or bedside management of post-surgical complications that do not require a return trip to the operating room.

MPFS Global Indicator	Procedure Category	Included Pre-Op Window	Included Post-Op Window	Separate E/M on Day of Decision?
000	Endoscopic or minor procedure	Day of surgery only	Day of surgery only (0 days after)	Yes, with Modifier 25 if significant and separately identifiable
010	Minor surgical procedure	Day of surgery only	10 calendar days following surgery	Yes, with Modifier 25 if significant and separately identifiable
090	Major surgical procedure	1 day prior to surgery + day of surgery	90 calendar days following surgery	Yes, with Modifier 57 on day before or day of surgery
MMM	Maternity care and delivery	Routine antepartum care	Routine postpartum care	Global obstetric package rules apply
XXX	Global concept does not apply (E/M, lab, radiology)	None	None	Standard NCCI bundling edits apply
YYY	Unlisted surgical procedure	Determined by MAC	Determined by Medicare Administrative Contractor (MAC)	Subject to contractor review
ZZZ	Add-on surgical code	Included in primary code	Tied strictly to the primary procedure’s global period	Governed by primary procedure code

Services Excluded from the Global Surgical Package (and Required Modifiers)

Certain clinical encounters and return procedures occurring inside a global window are excluded from the bundled payment and may be billed separately when supported by medical record documentation and the correct CPT modifier:

1. Initial Consultation or E/M Resulting in the Decision for Major Surgery (Modifier 57): If an E/M visit on the day before or the day of a 090 major surgery is the encounter where the surgeon first makes the clinical decision to perform the operation, append 57 to the E/M code. For 000 and 010 minor procedures, CMS prohibits Modifier 57; instead, a separately identifiable E/M on the same day requires Modifier 25.
2. Unrelated Postoperative E/M by the Same Surgeon (Modifier 24): When the operating surgeon (or a partner of the same specialty in the same group) evaluates the patient during the 10- or 90-day postoperative period for a condition completely unrelated to the surgery—or manages underlying chemotherapy or immunosuppressive therapy—append 24 to the E/M code and link an unrelated ICD-10-CM diagnosis.
3. Staged or Planned More Extensive Procedure (Modifier 58): Appended when a subsequent procedure during the postoperative period was prospectively planned at the time of the original operation, is more extensive than the original procedure (such as a definitive mastectomy following a diagnostic biopsy), or is for therapy following a diagnostic surgical procedure. Modifier 58 pays 100% of the MPFS fee schedule amount and starts a new global period.
4. Unplanned Return to the Operating Room for a Related Complication (Modifier 78): Whereas bedside wound care for a complication is bundled, a complication requiring a return trip to an operating room (including a cardiac catheterization suite, laser suite, or endoscopy suite) is separately billable with 78. Medicare reimburses a 78 claim at the intraoperative percentage only of the second procedure and does not start a new global period.
5. Unrelated Procedure by the Same Physician During the Postoperative Period (Modifier 79): Appended when the same surgeon performs an unrelated procedure during an active global period. It pays 100% of the fee schedule (subject to multiple-procedure rules) and starts a separate global window.
6. Split Surgical Care Across Transferring Physicians (Modifiers 54, 55, and 56): When one physician performs the surgery (54 — surgical care only) and transfers postoperative care via written agreement to an outside physician (55 — postoperative management only, billed with the exact surgery date and the date care was assumed), Medicare splits the global RVUs according to code-specific pre-op (`56`), intra-op (`54`), and post-op (`55`) percentages in the MPFS database.

How Is the Global Surgical Package Used in Clinical Research and Academic Medical Centers?

In academic medical centers (AMCs) and surgical clinical trials, global surgical billing intersects directly with clinical trial coverage analyses, Medicare Teaching Physician Rules, and Split (or Shared) E/M Visit Rules:

1. Medicare Teaching Physician Rules (42 CFR § 415.172)

Under 42 CFR § 415.172 and Medicare Claims Processing Manual Chapter 12, Section 100, a teaching physician billing Medicare Part B for surgical procedures or E/M visits involving residents/fellows must append Modifier GC (service performed in part by a resident under the direction of a teaching physician) or Modifier GE (service performed by a resident without the presence of a teaching physician under the Primary Care Exception, restricted to lower-level outpatient E/M codes 99202–99203 and 99211–99213):

• Single Complex or Major Surgery: The teaching surgeon must be physically present during all critical or key portions of the surgical procedure and must remain immediately available throughout the entire operation to furnish assistance if needed.
• Two Overlapping Surgeries: A teaching surgeon may bill for two overlapping procedures only if the critical or key portions of the two operations do not occur simultaneously. Once the critical portion of the first surgery is complete, the teaching surgeon must designate another qualified physician to be immediately available before scrubbing into the second room, and must document personal presence for the critical portions of both cases.
• Three Concurrent Surgeries: If a teaching surgeon is scheduled for three simultaneous operations, CMS classifies the surgeon’s role as supervisory rather than physician services to individual beneficiaries; none of the three procedures is billable under Medicare Part B.
• Minor Procedures (< 5 Minutes): The teaching physician must be physically present for the entire procedure.

2. Split (or Shared) E/M Visits in Facility Settings

A split (or shared) E/M visit is an Evaluation and Management encounter in an institutional facility setting (such as a hospital inpatient ward, outpatient hospital department, or emergency department) performed jointly on the same calendar date by a physician and a Non-Physician Practitioner (NPP: nurse practitioner, physician assistant, or clinical nurse specialist) who are in the same group practice:

• Substantive Portion Rule: Under CMS MPFS rules, the practitioner who performs the substantive portion of the visit bills the service and appends Modifier FS. The substantive portion is satisfied by the clinician who either spends more than half (> 50%) of the combined total time or performs the substantive part of the Medical Decision Making (MDM).
• Interaction with Global Surgery: Routine inpatient postoperative rounding performed by a surgical PA/NP or the surgeon during an active 10- or 90-day global period is already bundled into the global surgical fee and cannot be billed separately as a split/shared visit unless it meets the criteria for an excluded service (such as an unrelated condition with Modifier 24 or a decision for major surgery with Modifier 57).

3. Surgical Clinical Trial Coverage Analysis

When a clinical trial protocol mandates extra research-driven postoperative clinic visits on days 14, 28, and 60 after a 90-day global surgery, the trial’s Medicare Coverage Analysis (MCA) must account for the fact that routine clinical postoperative E/M visits within the 90-day window are already reimbursed through the global surgical fee and cannot be double-billed to Medicare or the trial sponsor.

Frequently Asked Questions

Does a physician assistant (PA) or nurse practitioner (NP) in the same surgical group fall under the surgeon’s global period?

Yes. CMS treats physicians and non-physician practitioners (NPs, PAs, CNSs) within the same group practice who provide routine postoperative follow-up for a group surgeon’s patient as part of the same billing entity. Routine postoperative visits by a surgical PA or NP within the 10- or 90-day window are bundled into the global surgical payment.

When does the 90-day global surgical period start and end?

A 090 global period spans 92 total calendar days: it includes 1 preoperative day (the calendar day immediately before surgery), the day of surgery itself, and the 90 consecutive calendar days immediately following the date of the surgery.

Can two surgeons from different specialties bill separately during the same operation?

Yes. When two surgeons with different skills (typically different specialties) are required to perform distinct components of a single surgical procedure simultaneously or sequentially during the same operative session, each surgeon bills the CPT code with Modifier 62 (Co-Surgeons), and each surgeon is bound by the procedure’s global postoperative period for their respective component of care.