§ 9789.16.1. Surgery -- Global Fee.
8 CA ADC § 9789.16.1Barclays Official California Code of Regulations
8 CCR § 9789.16.1
§ 9789.16.1. Surgery -- Global Fee.
A global surgical package refers to a payment policy of bundling payment for the various services associated with a surgical procedure into a single payment covering the operation and these other services.
(1) Definition of a Global Surgical Package. The National Physician Fee Schedule Relative Value File, Global Days column (labeled “Glob Days”), provides the postoperative periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 000, 010, 090. For workers' compensation, the global period will not apply to codes with “YYY”.
(A) Codes with “000” in the Global Days column are minor procedures or endoscopies with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure are generally not payable.
(B) Codes with “010” in the Global Days column are minor procedures or endoscopies with preoperative relative values on the day of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable.
(D) Codes with “ZZZ” are surgical codes related to another service and are always included in the global period of the other service. They are add-on codes that are always billed with another service. There is no postoperative work included in the fee schedule payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global period assigned is applied to the primary code.
(2) Components of a Global Surgical Package. A global surgical package is applied to all procedures with the appropriate entry in the Global Days column of the National Physician Fee Schedule Relative Value File. The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, 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 global fee includes payment for the following services related to the surgery when furnished by the physician who performs the surgery:
(C) 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 (OR). For the purposes of this section, an operating room 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 (unless the patient's condition was so critical there would be insufficient time for transportation to an OR);
(G) 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.
(F) 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 two 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 (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be performed in succession within 90 days of each other;
(4) Minor Surgeries and Endoscopies. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. A postoperative period of 10 days applies to some minor surgeries. The postoperative period for these procedures is indicated in the Global Days column of the National Physician Fee Schedule Relative Value File. If the Global Days column entry is “010”, no separate payment is allowed for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the 10-day period, the major surgery is payable separately. Services by other physicians are not included in the global fee for a minor procedure except as otherwise excluded. If the Global Days column entry is “000”, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. Separate payment is made in this instance.
(5) Physicians Furnishing Less Than the Full Global Package. There are occasions when more than one physician provides services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the postoperative, postdischarge care is split between two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services, except where permitted. When either modifier “-54” or “-55” is used, a percentage of the fee schedule is applied as appropriate. The percentages for pre-, intra-, and postoperative care of the total RVUs for major surgical procedures and for minor surgeries with a postoperative period of 10 days may be found in the columns Preoperative Percentage (“Pre Op”), Intraoperative Percentage (“Intra Op”), and Postoperative Percentage (“Post Op”), respectively, of the National Physician Fee Schedule Relative Value File. The intra-operative percentage includes postoperative hospital visits. Split global care does apply to procedures with “000” in the Global Days column of the National Physician Fee Schedule Relative Value File.
(6) Determining the Duration of a Global Period. To determine the global period for major surgeries, count 1 day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery. To determine the global period for minor procedures, count the day of surgery and the appropriate number of days (either 0 or 10 days) immediately following the date of surgery.
Credits
Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
History
1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).
2. Amendment of subsection (a)(1) filed 3-23-2016; operative 1-1-2016 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2016, No. 13).
3. Amendment of subsections (a)(1)(C) and (a)(5) filed 11-6-2018; operative 1-1-2019. Submitted to OAL for filing and printing only pursuant to Government Code section 11340.9(g) (Register 2018, No. 45).
This database is current through 4/26/24 Register 2024, No. 17.
Cal. Admin. Code tit. 8, § 9789.16.1, 8 CA ADC § 9789.16.1
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