Global surgery packages can be a billing landmine if not properly understood. These packages are designed to include all necessary services provided by a surgeon before, during, and after a procedure. But not knowing what’s bundled and what’s not can lead to denials or delayed reimbursements. So, let's break it down.
What's Typically Included in Global Surgery Packages
Global surgery packages bundle a variety of services related to a surgical procedure into one reimbursement. They're designed to cover pre-operative, intra-operative, and post-operative care. Here's the typical breakdown:
Pre-operative Visits: These are included if they occur after the decision to operate has been made. For instance, if a decision is made during a consultation that the surgery is needed, subsequent visits leading up to the actual procedure are bundled.
Intra-operative Services: The actual surgical procedure and any routine services provided during the operation are covered. Think of things like anesthesia (though this often gets its own separate billing) and surgical tools used.
Complications Following Surgery: If the surgeon must address complications in the operating room, those are bundled. However, if a return to the OR is not required, and it’s related to the original surgery, it’s typically included.
Post-operative Visits: Follow-ups within the post-operative period—either 10 or 90 days, depending on the surgery—are included. This includes visits where the surgeon checks on healing progress or addresses post-op concerns.
Post-surgical Pain Management: Typically managed by the surgeon, this is bundled unless a separate provider, such as an anesthesiologist, manages it.
What's Not Included
Some services are not part of the package and can be billed separately. Here’s what to watch for:
Initial Consultation: If the decision for surgery wasn’t made during this consultation, it can be billed separately. This is crucial for revenue—don't miss it.
Diagnostic Tests and Procedures: These are generally billed separately unless they’re part of the routine pre-operative workup.
Additional Unrelated Procedures: If during the global period a separate, unrelated procedure is performed, it can be billed outside the package. Just document thoroughly.
Return Trips to the OR for Complications: If a patient needs to go back to the OR for complications, this is billed separately with a modifier, usually Modifier 78 (Unplanned Return to the Operating/Procedure Room).
Modifier Requirements
Using the right modifiers is essential to ensure proper reimbursement. Here are common modifiers associated with global surgery packages:
Modifier 24: For unrelated evaluation and management services by the same physician during the post-operative period. This indicates that the encounter is separate from the surgery and must be documented clearly to justify it.
Modifier 25: Used for significant, separately identifiable evaluation and management services by the same physician on the day of the procedure. It's crucial for those encounters that require additional work-up.
Modifier 57: Decision for surgery. Used when the evaluation leads directly to the decision to perform surgery.
Modifier 58: Staged or related procedure or service by the same physician during the post-operative period. If a procedure is planned (staged) ahead of time or is more extensive than the original, use this modifier.
Modifier 78: Unplanned return to the OR/procedure room by the same physician following initial procedure for a related procedure during the post-op period.
Modifier 79: For an unrelated procedure or service by the same physician during the post-operative period. If it’s unrelated, modifier 79 is your friend.
Why It Matters
Understanding the details of global surgery packages can directly affect a practice's bottom line. Missteps often lead to denials or delayed payments. A strong grasp of what services are included—and how to properly document and bill those that aren't—keeps the revenue cycle running smoothly.
And the reality is, payers are not always transparent. They may have specific quirks in their pre-authorization requirements or documentation needs. Knowing these intricacies separates successful billing departments from the rest.
Final Takeaway
For billing teams, RCM directors, and practice executives, mastering global surgery packages is not just a technical necessity. It ensures that a practice gets reimbursed fairly for the services it provides. This requires diligence in understanding what’s bundled, identifying services that stand alone, and applying the right modifiers. Without this knowledge, practices could be leaving money on the table—or worse, facing frequent denials.
Are the nuances of global surgery packages complex? Yes. Can they be understood and managed effectively with the right approach? Absolutely. Don’t let your practice’s revenue be compromised by overlooking the details.
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