QUEST Integration – Global Fee for Surgery

Original Effective Date:

04/01/1999

Current Effective Date:

01/01/2015

A global surgery fee is paid for all necessary services rendered before, during and after a major surgical procedure. These services include, but are not limited to, pre-operative visits, the surgical procedure and post-operative services.

Pre-Operative Visits

Visits rendered up to three days before the surgery and related to the surgery are included in the global fee. These include visits to:

• Discuss the surgery to be performed
• Evaluate the patient’s physical condition and ability to tolerate the planned surgery
• Present and discuss the appropriate consent forms
• Prepare admission documents

Pre-operative Visits Excluded from Global Fee

The following pre-operative visits are not part of the global surgery fee and may be billed separately if the visit is necessary because:

• The surgical procedure is a diagnostic surgery
• The visit is a consultation (one that is not a hospital requirement)
• The patient has a serious medical risk, (e.g., congenital heart disease, blood disease, severe respiratory condition). This exam normally is performed by the physician currently treating the patient for the medical problem.
• An exam is performed before an unscheduled emergency surgery such as:
  • For acute illness, where immediate surgery is required (e.g., appendicitis, intestinal obstruction, heart failure).
  • For injuries caused by impact/collision, (e.g., auto accident, fall from high place, fight/assault).
  • The visit is an initial visit to evaluate the patient and establish the need for surgery

Post-Operative Visits

Post-operative services are inpatient or outpatient services directly related to a surgical procedure provided by the surgeon or any physician designated by the surgeon, generally up to 90 days after the date of the surgery (post-operative period).

Post-operative services performed in conjunction with minor surgery and endoscopic procedures can be provided in a post-operative period of up to 10 days. All other surgical procedures have post-operative periods of 90 days.

When these services are rendered by the surgeon, they are reimbursed through the global surgery fee and are not eligible for separate payment.

Post-operative services include but are not limited to:

• Evaluations
• Dressing changes
• Local wound care
• Removal of operative packs, cutaneous sutures, staples, lines, wires, tubes, drains, casts and splints
• Insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes
• Change and removal of tracheostomy tubes
• Post surgical pain management

Claims Filing Information

HMSA recognizes only the procedure code that applies to the surgery performed. Pre- and post-op services, except as noted above, are included in the global surgical fee. Please do not bill these services separately from the surgical procedure.

Division of Global Fee

When a physician other than the surgeon provides care that normally is included in the global fee, both the surgeon’s and physician’s claims must include the appropriate modifier code identifying the care component that each provided and the agreed upon fee distribution.

For example, the surgeon would bill using the surgical procedure code with modifier code – 54 if only the surgery was performed. If the surgeon also provided the pre-operative care in addition to the surgery, the surgeon should modify the surgical code with modifier – 99 (multiple modifiers) and indicate the modifiers that apply (– 54 and – 56). If a physician other than the surgeon provides only the pre-operative care, the surgical procedure code would be billed with modifier – 56. The physician providing the post-operative care would bill with the surgical procedure code and modifier – 55.

Revision History