Global care, assistants and postoperative services

Where you are

An operation can include care before and after the procedure. The global surgical package describes that relationship for payment purposes. To code another service during the period, you must determine who furnished it, how it relates to the operation and whether the applicable rules include it in the package.

This lesson uses Medicare's public guidance. Other payers may apply different policies. Do not confuse this surgical meaning of “global” with a diagnostic test that combines professional and technical components.

Find the global designation

Begin with the selected procedure and its applicable Medicare global designation. Medicare describes zero-day, ten-day and ninety-day postoperative packages, as well as other designations that need their own interpretation. Do not decide the period from the length of an incision or the patient's recovery time. [global-surgery-mln, Global Surgery Periods]

A ninety-day package includes the relevant preoperative day, the surgery date and the following postoperative period under the cited policy. A ten-day package begins with the procedure date and includes the specified postoperative days. The designation is a payment rule, not a prediction that every patient heals on the same schedule. [global-surgery-mln, Global Surgery Periods]

Write the procedure date and the applicable period in your worksheet. Then place the later encounter on that timeline. A later service cannot be classified accurately if the original operation or date is missing.

What ordinary follow-up includes

Medicare includes usual related postoperative care in the package. Routine follow-up for recovery does not become a separate visit merely because it requires an appointment or a separate note. Review the included-services list and the documented purpose of the encounter. [global-surgery-mln, Services Included in the Global Surgery Payment; claims-physicians-cms, 40.1]

Some services are outside the package under the applicable conditions. The distinction depends on the service and relationship to the surgery. A coder must not apply a blanket rule that every service during the period is included, or that every new diagnosis makes a visit separately payable.

The initial decision for major surgery

An E/M encounter that makes the initial decision for a major operation has a specific Medicare reporting pathway when it occurs on the day before or day of surgery. Confirm the major-surgery designation, timing and documented decision. A routine preoperative check after the decision has already been made is not the same encounter. [claims-physicians-cms, 40.2.A.4]

For a minor procedure, the ordinary decision to perform it is generally included. A significant, separately identifiable E/M service must meet the separate-E/M requirements discussed in the previous lesson. Do not choose between these pathways based on how alarming the diagnosis sounds. [ncci-general-2026, D]

Related, staged and unrelated procedures

When another procedure occurs during postoperative care, read its relationship to the original operation. Was it planned or staged? Was it more extensive treatment? Was it an unplanned return to an operating or procedure room for a related problem? Or was it unrelated to the original operation? These distinctions lead to different modifier instructions. [claims-physicians-cms, 40.2.A.6–8]

Do not equate “unplanned” with “unrelated.” An unexpected postoperative problem can be directly related to the original surgery. Equally, a procedure during the same calendar period can treat an unrelated condition. Use the report's clinical relationship, not timing alone.

Medicare also distinguishes the effect on the global period. A qualifying staged or unrelated procedure can start a new period, while the applicable related return-to-room pathway does not restart the original period. Confirm the exact instruction before calculating subsequent dates. [claims-physicians-cms, 40.2.A.6–8]

Worked postoperative comparison

Original fictional record: a surgeon performs an operation on August 3, 2026. The applicable global designation is supplied in the exercise as ninety days. On August 12, the surgeon documents ordinary recovery assessment and routine wound care. Investigate the included postoperative-care rule; a separate appointment does not alone support another E/M claim.

Change the August 12 record: the patient returns for an unrelated problem with a separately documented evaluation and management plan. Review the unrelated postoperative E/M instructions and the record supporting that relationship. Do not merely add a modifier because the diagnosis list contains another item. [claims-physicians-cms, 40.2.A.5]

Change it again: the patient requires an unplanned return to the operating room for a problem related to the operation. Now investigate the related return-to-room procedure pathway, not the unrelated-visit pathway. A routine office dressing change does not establish that same return-to-room circumstance. [claims-physicians-cms, 40.2.A.6]

Transfer of postoperative care: use the current rule

Medicare changed its instructions for reporting surgical care only in ninety-day packages beginning in 2025. The surgeon uses the applicable modifier when the surgeon does not intend to furnish the postoperative care, including circumstances involving an expected informal transfer. Do not rely on older summaries that limit this reporting obligation to a formal transfer agreement. [global-surgery-faq, questions 1–2]

The practitioner reporting postoperative management must still satisfy the applicable requirements. CMS's booklet describes the transfer documentation and reporting of the original surgery date. Distinguish the surgeon's current reporting obligation from the requirements for claiming a separately transferred postoperative portion. [global-surgery-mln, Furnishing Surgical Care Only or Postoperative Management Only]

The current CMS FAQ also describes an additional postoperative visit service for an eligible practitioner outside the surgeon's group. Being in the same specialty is not, by itself, disqualifying; being in the same group is. Consult the complete current requirements before proposing that service. This is a separate question from simply appending a transfer modifier. [global-surgery-faq, questions 3–5]

Assistants and other surgical roles

An assistant at surgery is not automatically a co-surgeon. Identify each practitioner's role and actual work in the operative documentation. Then check whether assistant services are permitted for the procedure and which reporting method applies to the practitioner's professional category. [claims-physicians-cms, 20.4.3]

Medicare distinguishes physician assistant-at-surgery reporting from services furnished by eligible nonphysician practitioners. Do not choose a physician modifier merely because the person assisted in an operating room. Likewise, an operative note listing two names does not establish that both performed separately reportable surgeon roles.

When the role is unclear, return to the complete report or seek clarification. The modifier cannot supply missing evidence about who performed which work.

Book drill

Locate the instructions for the initial major-surgery decision, unrelated postoperative E/M, staged procedures, related return to an operating room, unrelated postoperative procedures and assistant services. Pair those entries with the cited Medicare sections. Add a dated note that surgical-care-only reporting for ninety-day packages changed in 2025.

Checkpoint

Explain why an unplanned procedure can still be related, why routine recovery care is usually included, and why a second practitioner is not automatically a co-surgeon. Then distinguish the surgeon's current transfer-reporting obligation from an outdated formal-transfer-only summary.

Check the relationships

Global coding depends on the selected procedure, dates, documented relationship and practitioner role. Routine related recovery care belongs to the applicable package. Staged, related return-to-room and unrelated services have different instructions. Current Medicare surgical-care-only reporting for ninety-day packages includes expected informal transfers; older summaries can miss that change.

Sources

1. CMS — Global Surgery, MLN907166. 2026 service window; current cited policy. Accessed 2026-09-10.
2. CMS — Strategies for Improving Global Surgery Payment Accuracy: Frequently Asked Questions. 2026 service window; current cited policy. Accessed 2026-09-10.
3. CMS — Medicare Claims Processing Manual, Chapter 12: Physicians and Nonphysician Practitioners. 2026 service window; cited current manual sections. Accessed 2026-09-10.
4. CMS — Medicare NCCI 2026 Chapter I: General Correct Coding Policies. 2026. Accessed 2026-09-10.