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How To Properly Apply 5 Key Global Period Modifiers

By Grant Huang, CPC, CPMA ,Director of Content at DoctorsManagement.

CMS wants to eventually eliminate the global surgical package, but for now your physicians, coders, and billers must still comply with all of the bundling rules and modifier headaches that come with it.

To help you manage your 10-day and 90-day global period procedures, this article will discuss when and how to use the modifiers most relevant to the global period. Remember: The global surgical period or package refers to the complete set of care associated with a surgical procedure, including the pre-operative, intra-operative, and post-operative care. Typically most of the modifiers affect post-op care, as post-op care accounts for the vast majority of services that are provided beyond the actual surgery.

Zero days could still require a modifier. Keep in mind that procedures with 0-day global periods don’t have bundling issues associated with post-op care, though they will most likely need a modifier to be reported with a same-day E/M service. This would apply, for example, to any joint injection code, such as 20606 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]; with ultrasound guidance).

10-day global periods have no pre-op periods. Procedures with 10 global days are minor procedures such as removal of an orthopaedic implant. The 10-day global period begins the day of the surgery and continues for 10 days after the surgery – effectively making it a total of 11 days.

90-day global periods include 1 pre-op day. Procedures with 90 global days are major procedures and make up the bulk of orthopaedic surgeons’ services. The 90-day global applies to procedures such as joint replacements/revisions, open/closed fracture repairs, fusion procedures, and SLAP repairs. The 90-day global period begins the day prior to the day of the surgery and continues for 90 days after the surgery – effectively making it a total of 92 days.

Below are the modifiers that physicians will use when dealing with their most common procedures:

  • Modifier 57 – Decision for surgery  (major procedure only)
  • Modifier 58 – Staged or related procedure  during global period
  • Modifier 78 – Unplanned return to OR  during global period
  • Modifier 79 – Unrelated procedure  during global period
  • Modifier 24 – Unrelated E/M service  during global period
  • Modifier 57: Decision for surgery

For all services with a 90-day global period, related services rendered the day before the surgery are generally considered to be bundled into the code for the surgery. This is where modifier 57 (decision for surgery) comes in.

If an E/M service related to the surgery is performed either the prior to, or the day of the surgery, it will not be billable without modifier 57. To support modifier 57, the physician’s note must demonstrate that the E/M service was needed to ascertain the need for surgery. Modifier 57 applies most in situations where a patient is suddenly ill and requires a major intervention. If a major procedure has long been scheduled (e.g., a total hip joint replacement for a patient who was slowly losing mobility), then modifier 57 wouldn’t apply because the need for the surgery was determined long ago.

Remember that modifier 57 is used to show that a face-to-face visit was needed to determine the need for the procedure.

Modifier 58: Staged or related procedure during global period

When the patient returns during the global period for another procedure related to the procedure that triggered the global period, the follow-up procedure is considered bundled into the post-operative care. However, if modifier 58 is appended, such procedures can be billed.

Modifier 58 indicates that this subsequent procedure (or multiple procedures) was planned prospectively at the time of the original procedure (i.e., staged), or that it is more extensive than the original procedure. The follow-up procedure will begin a new post-op period (global period) once performed. The key word for modifier 58 is “staged or related.” It is either/or.

For example, if a surgeon performs limited debridement of an infected wound, then finds that the infection had spread and a more extensive debridement is needed, he has the patient return during the 90-day global period for the limited debridement. A more extensive procedure is carried out in the subsequent encounter. This subsequent procedure is more extensive than the first procedure, and thus modifier 58 is billable allowing full reimbursement of the second procedure.

For major procedures in which a cast or splint is needed for the patient, the initial cast/splint application is bundled into the surgery code, though the supply codes for the equipment are billable. Subsequent applications are billable with modifier 58.

Modifier 78: Unplanned return to OR during global period

When the patient experiences complications or any problem related to the surgery that triggered the global period, and those complications/problems are severe enough to warrant a return to the operating room (OR), then procedures done in the OR become separately billable with modifier 78.

Modifier 78 applies to procedure codes only, and requires that the return to the OR be a result of problems related to the original surgery. If the problems are unrelated, then modifier 79 (see below) is the correct modifier.

The same diagnosis code as the original procedure or related diagnosis codes would be expected, and the operative note should also make it clear that the procedures being done in the OR subsequent to the triggering surgery are related to that surgery.

Note that modifier 78 reduces payment for the procedures it is appended to by 20% to 30% depending on payer.

Modifier 79: Unrelated procedure  during global period

Similar to modifier 78, modifier 79 is used only with procedure codes for procedures done during the global period of a prior surgery. However, modifier 79 indicates that these subsequent procedures are wholly unrelated to the prior surgery.

A diagnosis different from that used for the original surgery is required, and the new surgery code or codes will begin new global periods if any apply. Because these procedures are not related to the original procedure, modifier 79 allows full payment at the usual fee schedule rate.

Modifier 24: Unrelated E/M service  during global period

All face-to-face E/M services done during the global period for a procedure is bundled into that procedure, if the visit is related to the diagnosis supporting the procedure. However, if the patient comes in during the global period for an unrelated problem (different diagnosis code), then modifier 24 applies.

Modifier 24 is used with E/M services only and the physician’s note must make it clear that the problems being evaluated and managed are not related to the problems that produced the medical necessity for the surgery. Different ICD-10-CM diagnosis codes must be used and the progress note must also be clear that the visit is unrelated to the surgery.

Grant Huang, CPC, CPMA (ghuang@drsmgmt.com). The author is Director of Content at DoctorsManagement.