Global Surgery and Related Services
Multiple Surgeries
Multiple surgeries are separate procedures performed by a physician on the same patient at the same operative session or on the same day. Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. Intraoperative services, incidental surgeries or components of surgeries will not be separately reimbursed.
Reimbursement is based on the following guidelines for multiple surgical procedures:
- 100% of the allowance for the highest valued procedure.
- 50% of the allowance for the second through the fifth highest valued procedures.
When more than five procedures are performed, reimbursement for the sixth and subsequent procedures will be reviewed on an individual consideration basis. Operative notes should be submitted with the claim when five or more surgical procedures are performed during the same operative session.
The limiting charge is 115% of the reduced payment amount for each procedure.
Reporting Guidelines
Providers do not need to report modifier 51 on claims. The claims’ processing system has hard-coded logic to append the modifier to the correct procedure codes.
However, if you do report modifier 51, follow the guidelines below:
- Report the highest valued procedure without the modifier.
- Report any additional surgical procedures with modifier 51.
Example
If billing for a repair of a rotator cuff (CPT code 23412), and a ligament release (CPT code 23415), and a claviculectomy (CPT code 23120), report the codes as follows:
- 23412
- 23415 51
- 23120 51
If surgeons of different specialties perform a different procedure (with specific CPT codes), multiple surgery rules do not apply. If one of the surgeons performs multiple procedures, the multiple surgery rules apply to that physician's services.
Reference
CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, Section 40.6
Multiple Endoscopy Procedures
Endoscopic procedures are identified on the Medicare Physician Fee Schedule (MPFS) by a multiple surgery indicator of 3.
When performing multiple procedures through the same endoscope, reimbursement is made for the highest valued endoscopy (100% of the allowance). The code with the second highest value will be paid at the allowed amount minus the allowed amount for the base code. If there are multiple endoscopic codes and the allowed amount for a code is less than the base code allowed amount, it will not be paid.
Example
While performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (CPT code 45380) and removes a polyp (CPT code 45385) from a different part of the colon.
The value of CPT codes 45380 and 45385 have the value of the diagnostic colonoscopy built in. Rather than paying 100% of the highest valued procedure 45385 and 50% for the next 45380, reimbursement is made for the full value of the higher endoscopy (CPT code 45378), plus the difference between the next highest endoscopy (CPT code 45380) and the base endoscopy (CPT code 45378).
Using the fee schedule amounts for 2026 for the following participating provider base rate for the state of Florida, the Jacksonville locality:
- 45378 - $169.59
- 45380 - $182.65
- 45385 - $229.49
Physician bills CPT codes 45385 and 45380. The lesser value code is billed with modifier 51, indicating multiple surgeries. Reimbursement is made based on the full value of 45385 ($229.49), plus the difference between 45380 and 45378 ($13.06) for a total of $242.55.
NOTE: If an endoscopic procedure with a Multiple Surgery indicator of 3 is billed with modifier 51 and other non-endoscopy procedures (procedures with a Multiple Surgery indicator of 1), standard multiple surgery rules apply.
For additional information on related and unrelated endoscopies, refer to CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, Section 40.6 C.
Global Surgical Package
The reimbursement for a surgical procedure includes a standard package of preoperative, intraoperative, and postoperative services. The preoperative period included in the global fee for major surgery is 1 day. The postoperative period for major surgery is 90 days. The postoperative period for minor surgery is either 0 or 10 days depending on the procedure. For endoscopic procedures (except procedures requiring an incision), there is no postoperative period.
• New Global Surgery Calculator - Our new global surgery calculator quickly determines the global period end date for surgical procedures. Simply enter the procedure date to obtain the surgical period end date - no manual counting required.
The Medicare approved amount for these procedures includes reimbursement for the following services related to the surgery when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, Ambulatory Surgical Centers (ASCs), and physicians' offices. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon. However, critical care services (99291 and 99292) are payable separately in some situations.
The following services are included in the reimbursement amount for global surgery:
- Preoperative visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures.
- Intraoperative services - Intraoperative services normally a usual and necessary part of a surgical procedure.
- Complications following surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room.
- Postoperative visits - Follow-up visits within the postoperative period of the surgery related to recovery from the surgery.
- Postsurgical pain management - By the surgeon
- Supplies
- Miscellaneous services - Items such as dressing changes; local incisional care; removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
The following services are not included in the reimbursement amount for a global surgery:
- The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.
- Services of other physicians, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or annotation in the discharge summary, hospital record, or ASC record.
- Visits unrelated to the diagnosis for which the surgical procedure is performed unless the visits occur due to complication of the surgery.
- Treatment for the underlying condition or an added course of treatment which is not part of the normal recovery from surgery.
- Diagnostic tests and procedures, including diagnostic radiological procedures.
- Clearly distinct surgical procedures during the postoperative period, which are not re-operations or treatment for complications (a new postoperative period begins with the subsequent procedure). This includes procedures done in 2 or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat epilepsy (CPT codes 61533-61536, 61539, 61541 and 61543), which may be performed in succession within 90 days of each other.
- Treatment for postoperative complications requiring a return to the operating room (OR). For this purpose, an OR is a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient's condition was so critical there would be insufficient time for transportation to an OR).
- If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately.
- For certain services performed in a physician's office.
- Immunotherapy management for organ transplants.
- Critical care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance from the physician.
For minor surgeries and endoscopies, the Medicare program will not pay separately for an evaluation and management service on the same day as a minor surgery or endoscopy, unless a significant, separately identifiable service is also performed, for example, an initial consultation or initial new patient visit. As stated earlier, there is no postoperative period for endoscopic procedures (unless an incision is required) and minor surgical procedures have postoperative periods of 0 or 10 days, based on the procedure.
For a listing of HCPCS and CPT modifiers, please visit the Modifiers page in the Billing & Coding section of our Claims & EDI Center of our website.
Add-On Surgical Procedures
CMS has assigned various surgical procedures with global surgery post-operative periods of "ZZZ".
These procedures, while surgical in nature, are add-on codes that are always billed with another procedure. There is no post-operative work included in the fee schedule amount for "ZZZ" codes.
When billed independent of another qualifying service, "ZZZ" procedures will be denied since they, by definition, are not stand-alone procedures. When billed in conjunction with a primary surgical procedure or qualifying service, both the primary and add-on code will be paid. The global surgery rules apply to the primary procedure.
Splitting Post-Operative Care
For guidance on splitting post-operative care, please see our article on Post-Operative Co-Management, Modifiers 54 And 55.
Bilateral Procedures
Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day. CMS has defined codes subject to the bilateral payment rule. Reimbursement for claims reporting bilateral procedures is 150% of the fee schedule amount. The limiting charge is 115% of that amount.
Procedure codes containing the terms "bilateral" or "unilateral or bilateral" in their definitions are not subject to bilateral pricing. Reimbursement for these services is 100% of the fee schedule for a surgical code. Procedure codes with terminology indicative of unilateral or bilateral services, as in CPT code 27395 (lengthening of hamstring tendon; multiple, bilateral) or CPT code 52290 (Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral) cannot be reported with the bilateral procedure code modifier 50 since the terminology for the code identifies the service as bilateral.
Certain procedures are not applicable to the 150% payment rule for bilateral procedures. Reimbursement is 100% of the fee schedule for each side, e.g., CPT codes 92225 and 92226. When performed bilaterally, report the codes with modifiers RT, LT or 50 to ensure proper payment.
For reporting guidance on modifiers for bilateral procedures, please see our Modifier 50 Fact Sheet.
Reference
Assistant At Surgery
Some surgical procedures require a primary surgeon and an assistant surgeon. Reimbursement will not be made for the services of assistants at surgery furnished in a teaching hospital which has a training program related to the medical specialty required for the surgical procedure and has a qualified resident available to perform the service.
Reimbursement for an assistant surgeon is limited to 16% of the fee schedule amount for the surgical procedure. The limiting charge is 115% of the assistant surgeon's fee schedule amount.
Additionally, the correct reimbursement amount for assistant-at-surgery services furnished by physician assistants (PAs), nurse practitioners (NPs) and clinical nurse specialists (CNSs) is 80% of the lesser of the actual charge or, 85% of 16% of what a physician is paid under the MPFS for surgical services.
For reporting guidance on modifiers for assistant at surgery, please see our article on Appropriate Use of Assistant At Surgery Modifiers and Payment Indicators.
Co-Surgery
Under some circumstances, the individual skills of two surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient's condition. In these cases, the additional physician is not acting as an assistant-at-surgery.
Co-surgery refers to surgical procedures involving two surgeons (each in a different specialty) performing parts of the procedure simultaneously, e.g., heart transplant or bilateral knee replacements. It is not always co-surgery when two doctors perform surgery on the same patient during the same operative session. Co-surgery is performed if the procedure(s) is part of and would be billed under the same surgical code. For example, when an otolaryngologist and a neurosurgeon perform an excision of a pituitary tumor (CPT code 61548), each physician reports CPT code 61548 with modifier 62 (two surgeons). Reimbursement for each surgeon is 62.5% of the MPFS amount.
Co-surgery has not been performed when each physician performed a separate surgical procedure which is reported under a different surgical procedure code, e.g., a hammertoe operation (CPT code 28285) performed by a podiatrist and a palma fasciotomy (CPT code 26040) performed by a hand surgeon. When two unrelated procedures are performed, each physician should bill for and be paid the full global fee for the procedure he/she performed.
Eligible Co-Surgery Procedure Codes
There are two categories of surgical procedures for which co-surgery may be covered. Codes not listed in either category are not eligible for reimbursement for co-surgery.
These categories are referred to as "indicators" in the MPFS database:
- Indicator 1: procedure codes can be paid for co-surgery when an operative report supporting the need for co-surgeons (of different specialties) is submitted with the claim.
- Indicator 2: procedure codes do not require documentation of medical necessity for co-surgery unless performed by surgeons of the same specialty. If co-surgeons are of the same specialty, you must submit operative reports.
When performing co-surgery, it is important to communicate with the other surgeon's office to be certain that claims are submitted properly.
For reporting guidance on modifiers for two surgeons, please see our Modifier 62 Fact Sheet.
Team Surgery
Team surgery also refers to a single procedure; however, it requires the skills of more than two surgeons of different specialties, working together to conduct various portions of a complicated surgical procedure. For example, a kidney transplant could involve the services of a general surgeon, urologist and/or vascular surgeon to remove the diseased kidney, to implant the donated kidney and to transplant the ureters.
CMS has identified those services for which team surgeons may be paid. Payment for codes defined as eligible for team surgery will be reimbursed on an individual consideration basis. The limiting charge is 115% of the fee schedule distributive share for each of the team physicians.
For reporting guidance on modifiers for two surgeons, please see our Modifier 66 Fact Sheet.
References