This article also features contributions from Elaine H. Song, plastic surgeon, and co-founder and CEO of WoundReference, Inc; and Eugene R. Worth, anesthesiologist, wound care and hyperbaric physician, and advisor and editor of WoundReference, Inc.


A common scenario occurring in wound clinics all over the nation is the request for follow-up wound services by surgeons during the post-operative global period. Wound clinic physicians might be seeing these patients with the intention of offloading some of the work for the surgeon or believing that they are increasing volume in their own clinics.

Wound clinic physicians must be aware of the surgical global packaging rules as they relate to the transfer of care from one provider to another. Documentation and proper billing methods are essential in order to meet CMS compliance standards and to ensure the rules are followed. Failure to do so could make you a target for audit and denials.

The global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure.

Medicare payment for the surgical procedure includes the pre-operative, intra-operative and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.

NOTE: The Medicare global surgical package does not apply to hospital-based outpatient departments (HOPD’S) that are paid under the Medicare ambulatory payment classification system (APC). The global surgical package only applies to the physicians who are paid under the Medicare physician fee schedule.

There are three types of global surgical packages based on the number of post-operative days.

  • Zero-day postoperative period (endoscopies and minor procedures)
  • 10-day postoperative period (minor procedures)
  • 90-day postoperative period (major procedures)

Global surgical payment

The following services are included in the global surgery payment when furnished by the physician who performs the surgery:

  • Pre-operative visits after the decision is made to operate.
  • For major procedures, this include pre-operative visits the day before surgery.
  • For minor procedures, this includes pre-operative visits the day of surgery;
  • Intra-operative services that are normally a ‘usual and necessary’ part of any surgical procedure;
  • All additional medical or surgical services required by the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room;
  • Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery;
  • Post-surgical pain management by the surgeon;
  • Supplies, except for those identified as exclusions; and
  • Miscellaneous services, such as dressing changes, local incision 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.

When physicians furnish only part of the global surgical package

More than one physician may furnish services included in the global surgical package. The physician who performs the surgical procedure may not furnish the follow-up care. Payment for that post-operative, post-discharge care may be shared among 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 provided all of the services.

The surgeon and the physician furnishing the post-operative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.

Using Modifiers “-54” and “-55” Transfer of Care

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:

Surgical care only (modifier “-54”); or Post-operative management only (modifier “-55”)

Rules for global surgery services billed with modifiers “-54” or “-55”

  • The same CPT code must be billed.
  • The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only.
  • The date of service is the date the surgical procedure was furnished.

Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to another (or a different) physician.

  • Modifier “-54” does not apply to assistant at surgery services.
  • Modifier “-54” does not apply to an ASC’s facility fees.

Modifier “-55” The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.” Documentation must include the following:

  • Use modifier “-55” with the CPT code for global periods of 10 or 90 days.
  • Report the date of surgery as the date of service and indicate the date care was relinquished or assumed.
  • Physicians must keep copies of the written transfer agreement in beneficiary’s medical record.
  • The receiving physician must provide at least one service before billing for any part of the post-operative care.


It is important that wound care physicians develop a relationship with surgeons who transfer care to their department during the global surgical period. Developing a methodical approach to accepting these surgical patients (with accurate and complete documentation) will benefit both parties. Cooperation between the two parties will ensure excellence in patient care, billing compliance, and appropriate reimbursement.


For tools and protocols on documentation and reimbursement in wound care and hyperbaric oxygen therapy, see the WoundReference Hyperbaric Oxygen Therapy Knowledge Base.

The WoundReference Hyperbaric Oxygen Therapy Knowledge Basefeatures guidelines and other important tools to promote high standards of patient care and operational safety within the hyperbaric program. The WoundReference Curbside Consultgives you actionable, specific answers from our advisory panel in a timely manner.