Current global surgery rules for Medicare have been in place since 1992, and most other payers follow Medicare guidelines. Still, questions remain. Here are some of the most common.

Q. What is Medicare’s global surgery policy?

A. In 1992, Medicare instituted its global surgery policy as part of Physician Payment Reform. It pays a single global fee for all necessary services furnished by the surgeon before, during and after the procedure. The Medicare Claims Processing Manual Chapter 12 identifies services that are and are not part of the global package (www.cms.gov/files/document/medicare-claims-processing-manual-chapter-12 ).

Sections §40.1.A and §40.1.C describe the components of a global surgery package. These include, among others:

• Preoperative visits after the decision is made to operate. This is generally construed to begin the day before surgery for major procedures. For minor procedures, visits by the same physician on the day of a minor surgery are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.
• Intraoperative services that are normally a usual and necessary part of a surgical procedure
• Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery
• All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room
• Supplies, except for those identified as exclusions
• Services by other physicians are not included in the global fee, except as otherwise excluded.

Q. What services are excluded?

A. Services excluded from the global surgical package and reimbursed separately are described in §40.1.B. They include:

• For major surgical procedures, the initial consultation or evaluation by the surgeon to determine the need for surgery is payable. The initial evaluation is always included in the allowance for a minor surgical procedure.
• Services of other physicians, except where the surgeon and the other physician(s) agree on a transfer of care (eg, co-management)
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery
• Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery
• Diagnostic tests
• Clearly distinct surgical procedures during the postoperative period that are not re-operations or treatment for complications.
• Staged procedures when the decision to stage the procedure is made prospectively or at the time of the first procedure
• Treatment for postoperative complications that require a return to the operating room (OR)
• If a less extensive procedure fails and a more extensive procedure is required, the second procedure is payable separately.

Q. How does “return to the OR” work?

A. Reoperations may be required following a failed retinal detachment repair, trabeculectomy or cataract surgery. When these necessitate a return to the OR, they are separately payable. An OR for this situation is defined as 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.

Treatment of postoperative complications that do not require a return to the operating room are part of postoperative care and not separately reimbursed. Nonetheless, there is a clear distinction in the regulation between treatment of a postoperative complication and staged, pre-planned procedures during the global period, even if they take place in-office instead of an OR.

For example, the surgeon plans to inject 5-FU following incisional glaucoma surgery with formation of a conjunctival bleb. This is characteristically different from an unplanned injection of a steroid to manage an unexpected postoperative acute iritis. The former is reimbursed, and the latter is part of postoperative care.

In either case, the supply of the injectable medication is reimbursed and not part of the global surgery package.

Q. Are diagnostic tests always separately payable?

A. While tests during the postoperative period are explicitly not part of the global surgery package, there are subtle nuances. Tests to confirm the expected outcome of a procedure are part of postoperative care. For example, extended ophthalmoscopy following retinal detachment repair is not separately reimbursed if performed to verify a successful outcome.

Likewise, external photography following successful blepharoplasty and gonioscopy following successful incisional glaucoma surgery are not separately reimbursed when performed on the operated eye(s).

In contrast, a diagnostic test to evaluate a failed procedure and help plan another surgery is covered, as is a test on the fellow eye to plan a subsequent surgery. OM

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .