The global surgical package is one of the most heavily tested concepts on the CPC exam — and one of the most misunderstood by beginner coders. Understanding it thoroughly is essential not just for the exam, but for accurate real-world coding. This article breaks it down completely, from what the global package includes to how modifiers are used to break it apart when necessary.
What is the Global Surgical Package?
When a surgeon performs a procedure and bills a CPT surgical code, that code does not just cover the operation itself. It covers a bundle of related services provided before, during, and after the surgery — all included in a single payment. This bundle is called the global surgical package.
The concept was created by Medicare and adopted widely across payers to simplify payment for surgical care. Instead of billing separately for every pre-operative visit, the surgery, and every post-operative follow-up, the surgeon receives one global payment that covers all of it within the global period.
What Is Included in the Global Surgical Package?
The following services are bundled into the global surgical fee and cannot be billed separately:
- Pre-operative visits the day before or the day of surgery (for major procedures)
- The surgical procedure itself including local infiltration and topical anesthesia
- Immediate post-operative care in the recovery room
- Complications following surgery that do not require a return to the operating room
- Post-operative visits during the global period that are related to the surgery
- Post-surgical pain management by the operating surgeon
- Supplies typically included with surgical procedures
- Miscellaneous services such as dressing changes and removal of sutures
What Is NOT Included in the Global Surgical Package?
Certain services can still be billed separately even during the global period:
- Treatment of a condition completely unrelated to the surgery
- Complications requiring a return to the operating room
- Services of other physicians who are not the operating surgeon
- Diagnostic tests and procedures ordered during the post-op period
- Clearly distinct surgical procedures during the global period (modifier -79)
- The initial consultation or evaluation that led to the decision for surgery (with modifier -57 for major procedures)
The Three Types of Global Periods
Not all surgical procedures have the same global period. Medicare assigns each surgical code one of three global period designations:
| Global Period | What It Means | Examples |
|---|---|---|
| 0-Day Global | No post-operative period. The surgical package only covers the procedure itself and same-day care. | Minor procedures like shave removals, needle biopsies |
| 10-Day Global | Post-operative period lasts 10 days after the procedure date. Related follow-up visits within 10 days are included. | Excision of skin lesions, simple repairs |
| 90-Day Global | Post-operative period lasts 90 days. Also includes one pre-operative day. Major surgical procedures fall here. | Appendectomy, CABG, total knee replacement, hysterectomy |
Key Modifiers for the Global Surgical Package
Modifiers are used to signal to payers that a service should be paid separately despite the global period rules. These are among the most tested modifiers on the CPC exam:
| Modifier | When to Use It |
|---|---|
| -24 | Unrelated E&M service during a post-operative period. The visit is for a completely different condition than the surgery. |
| -25 | Significant, separately identifiable E&M service on the same day as a minor procedure (0 or 10-day global). The E&M must be above and beyond what is included in the procedure. |
| -57 | Decision for surgery. The E&M visit resulted in the initial decision to perform a major (90-day global) surgery. Appended to the E&M code, not the surgery code. |
| -58 | Staged or related procedure during the post-operative period. The follow-up procedure was planned or is more extensive than expected. |
| -78 | Unplanned return to the OR for a related complication during the post-operative period. |
| -79 | Unrelated procedure during the post-operative period. The new surgery is for a completely different condition. |
Practical Example — Putting It All Together
Here is a scenario that illustrates global package rules in action:
A patient sees Dr. Smith on Monday for abdominal pain. After evaluation, Dr. Smith decides the patient needs an appendectomy (a 90-day global procedure). Surgery is performed on Wednesday. The patient returns two weeks later with a wound infection that Dr. Smith treats in the office. Four weeks later, the patient comes in for a completely unrelated sinus infection.
- Monday E&M visit: Bill with modifier -57 (decision for major surgery)
- Wednesday appendectomy: Bill the surgical CPT code — covers 90 days of related follow-up
- Wound infection visit: This is a complication related to the surgery — included in the global package, cannot bill separately
- Sinus infection visit: Completely unrelated — bill the E&M with modifier -24