Hi everyone and welcome back to our breaking code intro to medical coding series. In today's session, we'll dive into one of the most important and often misunderstood topics in procedural coding, the global surgical package and the modifiers that adjust or clarify services that are tied to your surgical procedures. We'll break down what's included in the global package, the difference between preop, intraop, and post-op care, and when and why to use modifiers like 24, 25, and 57, as well as common pitfalls and documentation tips to ensure accurate reporting. Whether you're preparing for your CPC exam or working to sharpen your real world coding skills, this lesson will help you confidently navigate your bundled services and modifier usage. So, let's get started. First, let's talk about what the surgical global package actually is. When a surgical procedure is performed, the services that are related to the procedure, meaning the preop care, the surgery itself, and the post-op follow-up care, those are typically bundled together and reported under a single code. This is what is known as the global surgical package. Rather than billing separately for each part of the surgical experience, the provider is reimbured with a single payment that covers the entire package of care. Most healthcare plans follow the CMS definition of your global package, but it is important to know that some payers may have their own guidelines and policies. That means that the length of the global period and which services are included can vary depending on the payer. These services can take place in various settings, including your hospitals, ambulatory surgical centers, or even a physician's office. As a coder, it is your responsibility to understand the payer's expectations and make sure that you're coding each encounter appropriately based on those rules. In your CPT manual, there is a specific list of services that are considered part of the global surgical package. These services are included in the overall reimbursement for the procedure, which means that they are not separately billable. You can find this list in the surgery guidelines section located just before the integimementary system codes. So, let's take a moment to find this section in your book. Once you've located the list, it is a good idea to highlight or bracket it. That way, you'll have a clear visual reminder that these services are part of the global package and they cannot be reported separately. Any service that does fall outside of this list and is supported by proper documentation can be built separately, but only when appropriate modifiers are used. The CMS global surgical package is based on whether a procedure is classified as major or minor surgery. And this classification will determine how many days are bundled into the global period. For major surgeries, the global package includes one day before the surgery, the day of the procedure, and 90 days of the posttop period. So that actually gives you a total of 92 days within that global period. For your minor surgeries, the global period starts on the day of the procedure and it either includes zero or 10 days posttop depending on the procedure. When there is a 10day global period, it actually totals 11. You have the day of the surgery plus 10 days following. So take a moment to mark or make note of these standard global periods within your code book as understanding these timelines will be crucial when you're determining whether a service should be considered part of the global package or if it should be reported separately. So how do you find the number of global days assigned to a procedure? You can look it up in the physician fee schedule relative value units or the RVU file and this is available on the CMS website. So this file doesn't just tell you the global period but it also breaks it down into the percentage of payment that applies to the preop, the intraop and the post-operative period. So let's take a look at an example. CPT code 26010 has a 10day global period, meaning it is considered a minor procedure. For this code, 10% of the payment is allocated to your preop care, 80% to the surgery itself, and then 10% for your posttop services. Now, let's compare it to the CPT code 26020, which has a global day of 90 days. That makes it a major procedure. Here we have 10% of the payment is still for your preop work, but 69% of that intraoperative portion and then you have a 21% for posttop care. This breakdown will help coders understand why certain services cannot be build separately because that reimbursement has already been built into the procedure based on this distribution here. When you look at your global days column on that RVU file, you might notice some codes don't have a number of days listed. Instead, you'll see letter indicators. These symbols are just as important to understand. If you see three M's, it means that the code is related to maternity care and the typical global period does not apply. So some examples will include CPT codes 59400 and 59612. The three X's indicate that the code does not fall under the global surgical package at all. These are usually evaluation and management services, anesthesia, radiology or lab codes. So the global concept should not apply to those codes. When you see three Y's, that tells you that it's an unlisted procedure code, and these are subject to individual pricing and review. And then finally, you have three Z's. These signal an add-on code. These codes are always tied to a primary procedure, and they inherit the global procedure of that primary service. So, how do you know if a surgery is considered minor or major? You can confirm it by researching the code on the payer's website or within their contracts. For Medicare payments, you can use physician fee schedule RVU files from the CMS website as it will be your go-to resource for accurate global period data. So what happens when a provider performs a service during the global period but that service is not part of the global package or the provider only performed a portion of the care. That's where your modifiers come in. Modifiers are added to your CPT codes to indicate that a procedure or service has been altered by a specific circumstance without changing the actual definition of the code itself. They help tell the full story of what was done and they can also impact how the claim is paid. So let's look at modifiers 54, 55, and 56, which are used when a provider only performs a portion of the global surgical package. Modifier 54 is used when the provider performs surgical care only. Modifier 55 indicates that they are doing post-op management only. And then modifier 56 represents preop management only. So if we think back earlier to our example of 26010 and that carried a 10-day global period, if a provider only manages the posttop care, then they would append modifier 55 and be reimbursed 10% of the total fee. If they only performed the surgical procedure using modifier 54, they would only receive 80% of the allowed amount. So these modifiers will be essential for reporting shared surgical care accurately and ensuring proper payment distribution. Now let's take a closer look at modifier 24. This modifier is used to report an unrelated evaluation and management or an ENM service and that would occur during the posttop period of a procedure but it's not related to the original procedure. It must be the same physician or qualified health care professional but it's for a separate issue. So let's walk through an example. On January 22nd a patient is seen for an injury to their right index finger. After evaluation, the physician determines that the finger needs to be amputated at the dip joint and they perform that procedure. So, this starts a 90day global period. Then on March 15th, that same patient returns to the same provider, but this time it's for a right leg infection. The new issue is clearly unrelated to the original finger procedure. Since the leg infection falls outside of the global in package, you would report the ENM visit with modifier 24 to show that it's a separate billable service. This modifier is crucial for separating your unrelated evaluation and management services from your routine posttop care, ensuring that your providers are properly reimbursed. Now, let's move on to modifier 25. This modifier is used when a provider performs a significant and separately identifiable ENM service on the same day as a minor procedure. And both services are clearly documented. By definition, a minor procedure is one that carries a zero or 10day global period. And your modifier 25 tells the payer that the ENM service wasn't just routine, but it was distinct and necessary in addition to the procedure. So here's an example. A patient presents to their family doctor with chest pain. The provider conducts a full workup for the chest pain, which qualifies as a billable ENM service. During that same visit, the provider also removes a skin lesion on the patient's arm. Since the lesion removal is a minor procedure, and the ENM work for chest pain is separate and medically necessary, the claim should be coded with a 99213 with a 25 modifier for the office visit and then your 11400 for the lesion removal. In this case, the modifier 25 is appended only to the ENM code, never to your procedure code. This modifier should only be used with your ENM codes and only when documentation supports that a significant separately identifiable service was performed. Now, let's take a look at modifier 57. This modifier is used when a provider makes the decision to perform a major surgical procedure during an ENM service. It applies when the ENM visit occurs either on the day before or the same day as a surgery. Remember, a major surgery is one that carries a 90day global period. So modifier 57 tells the payer that this ENM visit wasn't just a routine preop care. It was the moment that the provider made the clinical decision to move forward with the surgery. So here's an example. A patient presents to the emergency department with acute right lower quadrant pain that worsens with coughing and movement. After the evaluation, the provider diagnoses acute appendicitis and makes the decision to proceed with the appendecttomy immediately. So in this case you would report 99284 with a 57 modifier for the emergency department visit and then 44950 for the appendecttomy procedure. Because the decision for surgery was made during the ENM service and the procedure is considered major. Modifier 57 must be added to the ENM code to support separate reimbursement. Let's take a moment to look at a few more modifiers that can affect billing during the global period. These are especially important when additional procedures occur after the original surgery but within the same global window. First, we have modifier 58. This is used when a provider performs a staged or planned procedure or one that's more extensive than the original procedure during the posttop period. It's also used when a therapy or follow-up procedure is planned as part of the part of the treatment course. Modifier 58 signals that the new service was anticipated and related to the original procedure. So let's take a closer look at how modifier 58 works in a real coding scenario. A patient comes in for treatment of a non-healing foot ulcer and the provider performs an initial debrement to remove some of the damaged subcutaneous tissue. And then that procedure is coded as 11042. But the care plan doesn't stop there. During the posttop period, the provider schedules a second more intensive debrement to go deeper and remove any necrotic muscle tissue. That second procedure is coded as 11043. Because this follow-up procedure was planned as part of the patient's treatment strategy, it was more extensive than the first surgery and it was related to the initial surgery. we would append modifier 58 to the second procedure code. So in this case, you would report 11042 on the date of the initial debrement and then later 1043 with a 58 modifier for the more extensive staged debrement. This tells the payer that the second procedure was not a complication and it was not unplanned, but it was intentionally staged as part of the ongoing surgical management and it qualifies for separate reimbursement. Now, let's take a look at how modifier 78 is used. Modifier 78 is appended when there's an unplanned return to the operating room during the posttop period of a procedure. This modifier will tell the payer that a complication or a related issue has occurred that requires additional surgical intervention, but again it was not a part of the original plan. So here's an example. Patient undergoes gastric bypass surgery in January. A few weeks later in March, the patient develops an incisional hernia at the site of the original bypass incision. The provider takes the patient back to the operating room to repair the hernia. Since the hernia is related to the original surgery and the return to the operating room was unplanned, then you would append modifier 78 to the hernia repair code. This modifier helps distinguish that the procedure was necessary due to a complication. And while it is a related surgery to the initial procedure, it qualifies for an additional reimbursement. Though often there will be a reduced rate since global care has already been paid. Now, let's go over modifier 79. This one is used when a patient has a completely unrelated surgical procedure performed during the posttop period of a previous surgery. Unlike modifier 78 which deals with complications related to the original procedure, modifier 79 is used when the new procedure is for an entirely different issue that is unrelated to the first surgery. So here is an example. A patient has cataract surgery on the left eye in early June. Two weeks later, during the global period of the first surgery, the same patient returns for a carpal tunnel release on the right wrist, which is a condition that is totally unrelated to the eye surgery. Because the carpal tunnel procedure is not related to the cataract surgery in any way, you would report the carpal tunnel code with modifier 79 appended. This tells your payer, yes, we're still within the global period, but this new procedure is completely separate and it should be reimbursed independently. In addition to your surgical global package modifiers that we just talked about, there are many other modifiers that will help us tell the full story to our insurance carriers. Modifiers are essential tools in coding and they explain when a procedure or service has been modified by a special circumstance, whether it's about its location, the provider role, any repeat procedures, or other unique situations. Now, let's be honest, modifiers can feel a little overwhelming at first. There are quite a few of them, and it does take practice to know when and how to use them correctly. But don't worry, we're going to try to break them down clearly throughout this lesson. We'll start by reviewing the most relevant modifiers in this chapter, but you'll also see them again in your future lessons as we go through each body system by specialty. By the time that we're done, you'll be much more confident in using them and explaining them when necessary. So let's talk about modifier 22 which is used for increased procedural services. This modifier is appended when the work required to complete a procedure is significantly greater than what is typically expected. This could be due to extended time, technical difficulty, unusual anatomy, or a more severe patient condition. When you use modifier 22, you're essentially saying, "Yes, I performed the usual service, but it took more effort than normal." And here's why. Here's the key with modifier 22. You do have to submit the operative report with the claim. And within the documentation, it needs to clearly explain why the extra work was required. Whether that was due to unexpected bleeding, scar tissue, difficult access, or something else that made the procedure more complex than usual. So, here's an example. A patient undergoes a colonoscopy during the procedure and the provider removes a polip. But during the removal, the patient begins to bleed excessively and the provider spends an additional 30 minutes controlling the bleeding to avoid any complications. Because of that increased work and time, modifier 22 can be added to the procedure code to reflect the extra effort. So remember, modifier 22 should never be used with ENM codes, only on your procedural services. Now let's talk about modifier 50 which is used to indicate a bilateral procedure meaning that the same procedure was performed on both sides of the body during the same operative session according to your CPT guidelines. Unless the code description already specifies that it is a bilateral service, then you should report bilateral procedures by adding modifier 50 to your appropriate CPT code. But here's the tricky part. How you report it can vary depending on your payers. Some payers want the bilateral procedure reported on a single line with modifier 50 appended. Others might ask you to report it on two separate lines using modifier 50 on the second line only. And then some might require you to report it using the hickpix level two modifier specifically RT for the right side and LT for the left. So it is critical to check your payer's policy before submitting claims for bilateral procedures. What works for Medicare may not be the same for a commercial insurer. and incorrect reporting could delay or reduce your payment. Now, before you apply modifier 50 to a procedure code, you want to make sure that you pay very close attention to the code description itself. Some CPT codes already account for laterality, meaning that they specify whether the procedure is unilateral, bilateral, or both. So, here's the key. If a code says unilateral or bilateral within the descriptor, you do not append modifier 50. It's already built in. If a code says unilateral only, you'll often find a parenthetical note underneath that tells you exactly how to report that service bilaterally. Usually, it's by appending modifier 50. So, let's walk through some examples. First, take a look at CPT code 50592. This code will describe radio frequency ablasion of one or more renal tumors perccutaneously unilateral. And right below that code, there is a parenthetical instruction that states for bilateral procedure, report 50592 with modifier 50. So if the procedure is done on both kidneys, you would report 50592 with a 50 modifier. Now let's look at code 58900. This is for an ovarian biopsy and the descriptor states unilateral or bilateral. This means that the code already accounts for either one or both ovaries. So you would not need to use modifier 50 even if biopsies are done on both sides. The bottom line is you always want to read the code description and your parenthetical instructions carefully. They will tell you exactly when a modifier 50 is appropriate and when it's not. Now let's move on to modifier 51 which is used when multiple procedures are performed during the same session by the same provider. Modifier 51 indicates that more than one procedure was done and it helps the payer understand how the services should be reimbursed. The procedure with the highest RVU is reported first and then modifier 51 is appended to each additional procedure that is performed during that session. So here's an example. An orthopedic surgeon performs a closed treatment on a femoral shaft fracture on the left leg and in the same operative session they perform a closed treatment of a right knee dislocation. This would be reported with 27500 with an LT and 27552 with a 51 and RT for the knee dislocation. The LT and RT modifiers are used to indicate laterality and then your 51 is added to the second procedure to show that it was a part of the same session. Now, keep in mind, modifier 51 is not used on your ENM services, your physical medicine or rehab services, the provision of supplies like your vaccines, or any add-on codes since those are inherently bundled with a primary service. So, knowing when to use and when not to use your modifier 51 will be essential for clean claims and proper reimbursement. Now, let's take a moment to review modifier 59, which is used to indicate a distinct procedural service. So, in other words, a service that would normally be considered bundled, but due to the circumstances should be reported separately. You'll use modifier 59 in situations where services or procedures that aren't usually built together were performed and they meet specific conditions such as it's being done on a different anatomic site or organ system. It is performed through a separate incision or excision. It's involving a different lesion or it's addressing a completely separate injury or condition. So your modifier 59 will tell your payer, yes, these codes are typically considered part of the same service, but in this case, they're distinct and independently reportable. It is important to use this modifier only when no other more specific modifier is appropriate. In fact, CMS has created a set of X modifiers that we'll go over here in just a minute, and those will be more precise and useful in scenarios um where you have additional information. But if you're in a situation where there's no better fit, your modifier 59 is your go-to for ensuring separate reimbursement only when your documentation supports it. Now, let's talk about those X modifiers, which were created to provide more clarity and specificity than modifier 59 alone. These are often referred to as your X modifiers, and they help explain why a procedure or service that would normally be bundled should be built separately. So, here's a quick breakdown. XE is for separate encounter when the procedures were performed at different times on the same day. XS would stand for separate structure when the procedures were done on different anatomic sites or organ systems. XP would mean separate practitioner and these will be used when different providers are involved even within the same group. And then XU means unusual nonover overlapping services for rare situations where the procedures don't normally overlap, but in this specific case they did. So these modifiers are more descriptive and help reduce your inappropriate use of your modifier 59. Some payers, particularly Medicare, will even require the use of your X modifiers instead of your modifier 59 in many situations. So before you default to modifier 59, you want to ask yourself if one of the X modifiers will offer a more accurate explanation and it can make your coding cleaner and it can help reduce the chance of denials. Now let's look at an example to see modifier 59 in action. A patient undergoes a colonoscopy and during the procedure, the provider removes a lesion located proximal to the splenic flexure. That's the first service. During the same colonoscopy, a biopsy is also taken from a different lesion elsewhere within the colon. Under normal circumstances, these two services might be bundled, but because they were performed on distinct lesions, both codes are reportable and modifier 59 is appended to the second procedure to show that it was a separate service. So, you're telling your payer that these procedures are related to the same general procedure, which is the colonoscopy, but they were done on different lesions and therefore they should be reimbured separately. Also, don't forget that the additional guidance on modifier 59 can be found in the NCCI documentation on your CMS website. Those NCCI edits will tell you which codes are normally bundled and when it's appropriate to override the bundling using a modifier like 59. Next, let's go over a modifier 63, which is used for procedures that are performed on infants who weigh less than 4 kg. That's pretty much 8.8 lb. These procedures will come with significantly more complexity and risk. There's a greater difficulty maintaining temperature regulation, securing the IV access, and managing the overall physiological responses in such small, fragile patients. Modifier 63 helps account for the increased work and skill that is required in these situations. But here's the important part. Read the full definition in the CPT manual before using your modifier. There's a note that clarifies when it can be applied and not all of your codes will qualify. Some of your CPT codes already include the extra work associated with treating low birthw weightight infants and in those cases, modifier 63 would not be appropriate. To find out which codes are modifier 63 exempt, you want to check appendix F in your CPT manual. And it lists the codes that this modifier should not be reported. Now, let's look at modifier 76, which is used to report a repeat procedure or service that is performed by the same physician or other qualified healthcare professional. This modifier tells the payer, yes, we are billing the same CPT code again, but it is a distinct medically necessary repeat of the service, not an error or duplicative service. So, here's an example. A patient comes to the ER with trauma to the chest. A two view chest X-ray is performed, which reveals a pumathorax, which is trapped air within that chest cavity. The provider places a chest tube to relieve the pressure. After the chest tube is placed, the provider orders a repeat two view chest X-ray in order to confirm that the tube is correct in the position. In this case, you would report 71046 for the initial chest X-ray and then 71046 with a 76 modifier for the repeat X-ray that is performed by the same provider. Modifier 76 is the key to explaining that both services are intentional, necessary, and separate, and not an accidental duplication. Now, let's take a look at modifier 77, which is used when a procedure or service is repeated by a different physician or other qualified health care professional. This modifier is very similar to modifier 76, but the key difference is who performs the repeat procedure. Modifier 76 is for the same provider and modifier 77 is for a different provider. So here is an example. The patient visits their family doctor for chest pain and the provider performs an EKG to evaluate the symptoms and then refers to the patient to a cardiologist for further evaluation. That same day, the cardiologist also performs an EKG, which is a repeat service but by a different provider. So in this case you would report 9300 0 for the EKG performed by the family doctor 9300 0 with a 77 for the EKG performed later by the cardiologist. Modifier 77 tells the patient that although the same procedure is being buil again, it was done by a different provider and both services are medically necessary and reportable. Now, let's take a look at two modifiers that apply when multiple surgeons are involved in performing a procedure. Modifier 62 and modifier 66. Modifier 62 is used when two surgeons work together as primary surgeons, each performing a distinct part of a single surgical procedure. This is not assistant at surgery work, but both surgeons are responsible for significant portions of the operation. Each surgeon must submit the same CPT code, append modifier 62, and document a separate operative note that outlines the portion of the procedure that they have personally performed. Now, let's look at modifier 66, which indicates that a surgical team was used. This is typically reserved for highly complex procedures that require the skills of multiple physicians, often across different specialties. You'll commonly see modifier 66 with surgeries like your organ transplants, where coordinated simultaneous work by several providers is essential. When modifier 66 is appended, it tells the payer that this wasn't a standard operation that it required a team-based approach due to the complexity and risk of the procedure. Let's cover our assistant surgeon modifiers, specifically modifiers 80, 81, and 82. These modifiers are used to indicate when an additional surgeon is assisting with a procedure but not acting as a co-surgeon or part of a surgical team. Starting with modifier 80. This is used when one physician assists another for the entire procedure or a significant portion of it. In this case, the assistant surgeon reports the same CPT code as the primary surgeon and then appends modifier 80 to indicate their supporting role. Next, we have modifier 81, which is for minimal assistant surgeon. This applies when a surgery was planned to be performed solo, but unexpected circumstances arose during that procedure and a second surgeon is brought in to assist, but only briefly. that assisting physician would report the same surgical code with modifier 81 to indicate their involvement was limited. Lastly, we have modifier 82 that is used in a teaching hospital where a qualified resident surgeon is not available to assist. When that happens, a second fully licensed surgeon may be called in to assist. that assisting provider would report the surgical procedure with a modifier 82 to show that they stepped in due to the unavailability of a resident. These modifiers can help ensure appropriate reporting and payment when multiple providers are involved without misrepresenting the level of participation. Let's talk about two important modifiers that are used for services that involve both a professional and technical component. Modifiers 26 and TC. These are called global ancillary modifiers and they're most commonly used with procedures like radiology and diagnostic testing where the service is made up of two distinct parts. the technical component which involves performing the test and operating the equipment and then your professional component which includes the physicians interpretation and written report. Modifier TC is used to indicate that only the technical component was provided and modifier 26 is used to indicate that only the professional component was provided. If both components are provided by the same provider or facility, the service is reported without any modifiers and this is known as your global service. So here's an example. A patient comes into the office with wheezing and chest congestion. The provider performs a two view chest X-ray using inoffice equipment but sends the images to a radiologist in order to interpret. In this case, the office would report 71046 with a TC to represent the technical service using the equipment and capturing the images and the radiologist would report 71046 with a 26 for the interpretation and written report. However, if the same provider both performs and interprets the X-ray in the office, they would report 71046 with no modifiers indicating that the global service was provided. These modifiers will help communicate who did what and to ensure appropriate reimbursement when services are shared between your providers. Now, let's go over three lab specific modifiers that you'll want to be familiar with. 90, 91, and 92. We'll start with modifier 90, which is used when lab services are performed by someone other than the treating provider. Most commonly, this modifier is used when a provider purchases lab services from an outside lab. For example, if a physician sends a blood sample to an external lab for processing, modifier 90 would be appended to the lab code to reflect that the test was referred out. Next, you have modifier 91, which is used for a repeat clinical diagnostic lab test. This modifier is appropriate when the same test is repeated on the same day in order to obtain new results, such as testing multiple arterial blood gases throughout a 24-hour period. However, it is important to not use modifier 91 if the test was repeated only to confirm the results of the first one or the test had to be repeated due to equipment failure or error. In those situations, the repeat test isn't considered a new medically necessary diagnostic service. Finally, modifier 92 is used to indicate alternative lab platform testing, typically when a singleuse transportable kit or device is used for point of care testing. This is common in situations like HIV screening tests for CPT codes 86701 to 86703 where the test is performed on site using a portable handheld instrument rather than traditional lab equipment. These modifiers can help differentiate where, how, and why your lab services are performed. and then they ensure appropriate billing for tests based on clinical setting and intent. Let's finish up by taking a quick look at a few anesthesia specific modifiers that you may encounter. 23, 47, and your physical status modifiers. First, modifier 23 is used to report unusual anesthesia. You'd use this when a procedure that doesn't normally require general anesthesia ends up needing it due to special circumstances. For example, extreme patient anxiety or a complex case involving a child. Next, you have modifier 47 which is used when the surgeon personally administers the anesthesia such as a regional or spinal block instead of involving a separate anesthesia provider. This modifier is not reported on your anesthesia codes themselves but on the surgical code to indicate that the surgeon also provided the anesthesia service. And finally, we have the physical status modifiers which range from P1 to P6. These modifiers will describe the patients overall health status at the time that anesthesia is administered. P1 is for a normal healthy patient. P2 is a patient with a mild systemic disease. P3 is a patient with a severe systemic disease. P4 is a patient with severe systemic disease that is a constant threat to life. P5 is a more bound patient that is not expected to survive without your operation. And P6 is a declared brain dead patient whose organs are being removed for donation. These status modifiers will help communicate risk level and can impact how anesthesia services are valued and reimbursed. So, thanks so much for watching. I hope this lesson on the global surgical package and modifiers helped clarify some of the most important and often confusing parts of CPT coding. If you found this helpful, don't forget to subscribe and follow the channel so that you never miss a new lesson. Follow us for more coding tips, updates, and support. And if you know someone who is studying for their CPC exam or working in the field, be sure to share this video with them. Your support helps us keep creating valuable content for your coding community. Thanks again, and I'll see you in the next video.