Global Surgical Packages: What Can't Be Billed Separately in 2026

What Is a Global Surgical Package?

CMS defines the global surgical package as all the necessary services normally furnished by a surgeon before, during, and after a procedure. Services provided preoperatively, intra-operatively, and postoperatively are considered part of this global surgical package and are included in the cost of the surgery, whether rendered by the surgeon or by members of the same group. In plain terms: you pay once, and that payment is supposed to cover the whole episode of surgical care.

The global surgery policy was developed by CMS as part of the Resource-Based Relative Value Scale (RBRVS) system implemented in 1992. The concept was based on typical practice patterns — the idea that surgeons routinely provide pre-operative evaluation and post-operative management as part of the complete surgical service, so the single surgical fee should encompass all of it. The governing regulation is found at 42 CFR Part 414, which gives CMS authority to establish a uniform national global surgery policy — including pre- and post-operative periods, intra-operative services, and payment modifiers — as part of the Medicare Physician Fee Schedule.

Reimbursement for a surgical procedure includes all services and supplies that are routine, integral, and necessary to perform the procedure. These services are not eligible for separate reimbursement, are bundled into the global surgical package, and will be denied if billed separately during the applicable global period. Most commercial insurers follow the same framework. Medicare's global surgery package rules are the standard framework, and most commercial payers follow the same rules — but variations exist.

How Long Does the Global Period Last?

Medicare payment for most surgical procedures covers both the procedure and post-operative visits occurring within a global period of either 10 or 90 days following the procedure. CMS assigns one of several global period codes to every surgical procedure on the Physician Fee Schedule:

A major surgical procedure is defined in the regulation as a surgical procedure for which a 10-day or 90-day global period is used for payment under the physician fee schedule. If you had a knee replacement, a spinal fusion, or open abdominal surgery, your surgeon's fee is almost certainly a 90-day global package — meaning three months of routine follow-up visits are already paid for inside that single surgical CPT code.

What Exactly Is Bundled Inside the Package?

Per the CMS Medicare Claims Processing Manual (Chapter 12) and 42 CFR Part 414, the following services are included in — and cannot be separately billed by — the operating surgeon during the global period:

• Pre-operative visits after the decision to operate has been made (the day before surgery for 90-day procedures; the day of surgery for 10-day procedures)
• The surgical procedure itself, including local anesthesia administered by the surgeon
• All intraoperative services normally part of the surgery
• Routine post-operative office visits related to the procedure during the global window
• Post-surgical pain management provided by the surgeon
• Dressing changes, local incisional care, removal of sutures, staples, drains, splints, and casts
• Insertion and removal of urinary catheters, nasogastric tubes, and peripheral IV lines
• Complications following surgery that don't require a return to the operating room
• ICU/critical care visits by the surgeon if related to the procedure

These services are included in the payment for a global surgery when furnished by the provider who performs the surgery, including preoperative visits, intraoperative visits, complications following surgery, postoperative visits, postsurgical pain management, and miscellaneous services such as dressing changes and removal of sutures, staples, drains, casts, and splints.

Billing a separate E/M code for a routine postop visit within the global window is a common bundling violation. As a patient, if you see a line-item charge for a "post-operative office visit" or a "follow-up evaluation" from the same surgical group within the global period — and your surgery carried a 10- or 90-day global period — that charge is worth challenging. For guidance on reading every line of your bill, see Understand Your Itemized Hospital Bill: How to Read Every Line (2026).

What CAN Be Billed Separately — and When?

Not everything during the post-operative window is automatically bundled. CMS does not include certain services in the global surgical package. The surgeon's initial evaluation visit — where the decision to perform major surgery is first made — is not part of the global package and can be billed separately using modifier 57.

If other providers who are not the surgeon perform surgery-related services, those are excluded from the package unless there is a documented agreement to transfer care. Follow-up visits for conditions entirely unrelated to the surgery are also not included in the global surgery package. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon — however, critical care services (CPT codes 99291 and 99292) are payable separately in some situations.

The critical mechanism for legitimate separate billing is the use of a billing modifier. Here are the ones you'll most often see on a surgical bill:

• Modifier 24 — E/M visit during the global period for a condition completely unrelated to the surgery
• Modifier 25 — A significant, separately identifiable E/M service on the same day as a minor procedure
• Modifier 57 — The E/M visit where the decision to perform major surgery was made (billed the day before or day of surgery)
• Modifier 58 — A staged or related procedure that was planned at the time of the original surgery
• Modifier 78 — An unplanned return to the OR for a complication during the global period
• Modifier 79 — A procedure during the global period that is entirely unrelated to the original surgery

These modifiers are critical for surgical practices. They signal to payers that a service being billed during or around a global period is not included in the global package and should be paid separately. As a patient, if you see a line-item charge with one of these modifiers, you have the right to ask the provider for documentation proving the service was genuinely separate from your surgery. Documentation in the patient's medical record should clearly indicate that the subsequent surgical procedure or visit is unrelated to the prior original surgery.

Common Improper Charges to Watch for on Your Bill

The most frequent pattern of improper global-period billing that appears in hospital and surgical practice claims involves routine care being unbundled into separate line-items. Billing for services that are included in the global package results in overpayment, potential recoupment, and audit risk. For patients, that means you or your insurer may have been charged twice for the same care.

CMS's own data has identified a persistent problem with global period accuracy. CMS currently has several years of data showing that the post-operative visits during the global period are not occurring, yet providers are still being paid for these visits under the current global payment policy. In its CY 2026 Physician Fee Schedule final rule (CMS-1832-F), CMS solicited public comment on strategies for improving the accuracy of global surgical service valuation and payment. This is an active, unresolved policy issue — which means the billing environment patients face today includes real risk of error.

Here are the specific charge types most worth flagging when you review a surgical bill:

If your bill contains charges that appear to duplicate bundled services — especially without a modifier — that's a strong signal to request your itemized bill and EOB together. The article What Is Upcoding? How Hospitals Inflate Your Bill — and How to Spot It covers the broader pattern of billing inflation that often accompanies unbundling errors.

How to Dispute an Improper Global-Period Charge

Start by getting two documents side-by-side: your itemized hospital or surgical bill, and your Explanation of Benefits (EOB) from your insurer. The EOB will show what your insurer actually paid and whether it flagged any denials. If you see denial code CO-97 or PR-97, the payer is saying "this service is already included in another service you billed." That's your confirmation a bundling rule was triggered — and if your insurer caught it, check that the charge wasn't passed to you as "patient responsibility" anyway.

If you're on Medicare, your Medicare Summary Notice will list each charge and its payment status. For a detailed walkthrough of reading both documents, see Medicare Summary Notice vs. Commercial EOB: How to Read Each in 2026.

To formally dispute an improper unbundled charge, follow these steps:

1. Request your itemized bill in writing. Ask for the CPT code on every line, not just a description.
2. Identify the global period for your primary surgical CPT code. You can look up global period indicators in the CMS Medicare Physician Fee Schedule lookup tool on cms.gov.
3. Compare the date of each disputed charge to your surgery date. If it falls within the global period window, flag it.
4. Check whether a modifier (24, 25, 57, 58, 78, or 79) is attached. If not, the provider has no documented basis for separate billing.
5. Submit a written dispute to both the provider's billing department and your insurer. Reference the CMS global surgery policy under 42 CFR Part 414 and the Medicare Claims Processing Manual, Chapter 12.
6. If the insurer has already paid the unbundled charge, ask them to recoup it and re-adjudicate the claim under global surgery bundling rules.

If a disputed balance ends up in collections before it's resolved, review your rights under the CFPB's medical debt rules — covered in detail at When Can a Hospital Send You to Collections? 2026 Rules. And if your insurer and the provider are at an impasse over what should be separately reimbursable, the federal Independent Dispute Resolution process may apply — see What the Federal IDR Process Actually Means for Your Medical Bill in 2026.

About VerifyDoc: We help patients identify errors and overcharges on medical bills. We publish guides on hospital billing, the No Surprises Act, and disputing medical charges, updated as federal and state rules change.