Revenue that happens away from the office
General surgeons work in clinics, emergency departments, operating rooms and hospital wards, often on the same day. Much of the billable work — consultations, decisions for surgery, procedures and inpatient visits — happens in the hospital, where charges are easy to miss and slow to reach the billing team. Once the procedure is billed, the global surgical package decides which follow-up visits can be billed at all.
The global surgical package
Each procedure has a global period of 0, 10 or 90 days. For major (90-day) procedures, the package includes the pre-operative visit the day before or the day of surgery, the operation, routine post-operative visits and treatment of complications that do not require a return to the operating room. Post-operative visits are often recorded with 99024 so the practice can track them, though they are not paid.
Modifiers that decide payment
| Modifier | When it applies |
|---|---|
| 57 | E/M on the day before or day of a major procedure, when the visit resulted in the decision to operate |
| 25 | Significant, separate E/M on the same day as a minor (0- or 10-day) procedure |
| 24 | E/M during the post-operative period for an unrelated problem |
| 58 | Staged or planned related procedure, or a more extensive procedure, during the global period |
| 78 | Unplanned return to the operating room for a related problem, such as a complication |
| 79 | Unrelated procedure during the global period |
Using 25 where 57 belongs, or billing a related return to the OR without 78, is a common source of denials or underpayment. Medicare does not pay consultation codes, so hospital consultations are billed with the appropriate E/M codes for the setting.
Multiple surgeons and multiple procedures
- Multiple procedures in one session are ranked by value; secondary procedures carry modifier 51 or are reduced by the payer automatically.
- Bilateral procedures use modifier 50 or RT/LT as the payer requires.
- Assistant at surgery is billed with 80 or 82 for physicians and AS for non-physician practitioners, only for procedures the payer allows an assistant on.
- Co-surgeons each report modifier 62 and their own operative note when two surgeons perform distinct parts of one procedure.
Code families that changed
Anterior abdominal hernia repair codes were restructured in 2023 (49591–49618): the same codes apply to open, laparoscopic and robotic repairs, and are chosen by total defect size, whether the hernia is reducible or incarcerated, and whether it is initial or recurrent, with mesh placement included. For many other operations — cholecystectomy and colectomy, for example — open and laparoscopic versions have different codes and values. Operative notes need to state defect size, approach and findings clearly for the code to be supported. For procedures in surgery centers, see ASC billing.