Global periods define whether post-procedure services are bundled or separately payable. Cardiology is one of the most complex specialties in this area because most catheter-based procedures have 0-day globals, while device implants and surgical procedures carry 90-day global periods.
Understanding how global periods work is essential for correct reimbursement, audit-proof documentation, modifier usage, and compliant billing.
This guide provides a complete educational breakdown designed for physicians, coders, compliance officers, and practice managers. It focuses on real-world cardiology workflows, payer expectations, and common audit triggers.
Understanding the Global Surgical Package
The global surgical package is a set of services bundled into the payment for a procedure. These services include:
Preoperative Services
- Routine pre-op evaluation
- H&P related to the planned procedure
- Consent discussion
- Pre-procedure instructions
Intraoperative Services
- Procedure itself
- Typical technique-related work
- Local anesthesia
- Required imaging guidance (when bundled into CPT)
- Closure and stabilization
Postoperative Services
Bundled if the procedure has a global period:
- Routine follow-up visits
- Wound checks
- Device pocket checks
- Management of typical post-op complications in the clinic (NOT requiring return to cath/EP lab)
- Pain management related to the procedure
- Dressing changes
- Removal of sutures/skin glue/staples
What is NOT Bundled
Always separately billable:
- Diagnostic tests
- ECG/Echo/Stress tests
- Holter/monitoring
- Pacemaker/ICD interrogation and programming
- Unrelated E/M services (modifier 24)
- New problems unrelated to the procedure
- Return to procedure room due to complication (modifier 78)
- Unrelated procedure or surgery by the same provider (modifier 79)
0-Day Global Period Procedures in Cardiology
A 0-day global period means only the procedure on that date is bundled.
Everything the next day and beyond is separately payable when medically necessary.
Most catheter-based procedures fall under 0-day globals, including:
Percutaneous Coronary Interventions (PCI)
- 92920–92944 series
- Includes:
- Coronary angioplasty
- Coronary stent placement
- Atherectomy
- CTO PCI
- Thrombectomy (if separately billable)
Diagnostic Heart Catheterization
- 93451–93461 series
- Includes:
- Left heart cath
- Right heart cath
- Combined cath
- Coronary angiography
- Ventriculography when included
Intravascular Imaging & Physiology
- IVUS (92978/92979)
- OCT (92941/92942 depending on vessel)
- FFR (93571/93572)
Peripheral Vascular Interventions
- 37220–37235 series
- Includes:
- Iliac, fem-pop, tib-per angioplasty
- Stenting
- Atherectomy
- Thrombolysis/thrombectomy (if percutaneous)
EP Diagnostic Studies
- 93600–93662 (if no ablation)
- Includes:
- Basic EP study
- Signal recording
- Pacing maneuvers
- Advanced mapping (except when bundled into ablation)
Cardioversion
- 92960 (external)
- 92961 (internal)
Temporary Pacemaker Placement
- 33210
- 33211
- 33212
Why This Matters
With 0-day global periods:
- Follow-up visits are billable
- New complaints are billable
- Diagnostic testing is always separately payable
- No modifier 24 is required because no postoperative period exists
This simplifies billing compared to device procedures.
90-Day Global Period Procedures in Cardiology
90-day global periods apply to major cardiac surgeries, device implants, and open vascular procedures. These require strict billing discipline because postoperative visits are bundled.
Pacemaker & ICD Procedures
- 33206–33208 (pacemaker insertion)
- 33249 (ICD insertion)
- 33225 (LV lead insertion)
- 33227–33229 (PM generator change)
- 33262–33264 (ICD generator change)
CRT-P / CRT-D Implants
- 33249 + 33225
- 33208 + 33225
- Depending on device type and the number of leads.
Surgical Lead Procedures
- Epicardial lead insertion
- Open pocket revisions
- Surgical removal of devices (thoracotomy)
Open Vascular Surgeries
- Open embolectomy
- Bypass graft procedures
- Endarterectomy
- Open thrombectomy (34201–34203)
Many payers treat major EP ablations as extended global.
While technically 0-day in CPT, payers may apply de facto global rules to:
- 93653 (SVT)
- 93654 (VT)
- 93656 (AF ablation)
Always verify payer-specific rules.
What Is Bundled for 90-day Procedures
- Wound care
- Pocket checks
- Post-op assessments
- Device threshold checks related to implantation
- Management of expected healing issues
- Medication management related to the surgery
What Is NOT Bundled
- New diagnoses
- Unrelated symptoms (shortness of breath, new arrhythmia, chest pain)
- Device interrogation/programming (usually billable)
- Diagnostic tests (ECG, Echo, Stress testing, Holter)
- Return to OR/EP/Cath lab for complications (modifier 78)
Billing E/M Visits During a 90-Day Global Period
Modifier 24 – Unrelated E/M
Used when the visit is:
- For a new problem, OR
- Unrelated to surgery, OR
- A chronic condition requiring separate management
Examples:
- Patient with an ICD implant develops a hypertension crisis
- A pacemaker patient presents with pneumonia
- CRT-D patient presents for AF management
Documentation must clearly state:
- Why is the condition unrelated
- What was evaluated or treated
- Why was separate work necessary
Modifier 25 – Significant, separately identifiable E/M on the same day as a minor procedure
Not typically used in cardiology unless performing:
- Cardioversion
- Temporary pacemaker placement
- Pericardiocentesis
- Diagnostic tests requiring interpretation
DO NOT misuse modifier 25 for routine pre-procedure evaluation.
Modifier 57 – Decision for Surgery
Used for:
- Pacemaker / ICD implant
- Generator replacements
- Surgical vascular procedures
Modifier 58 – Staged or related procedure during global
Use when:
- A staged PCI procedure occurs during a device global
- LV lead insertion planned following initial CRT-P implant
- Staged revascularization planned based on initial cath findings
Modifier 78 – Return to OR for related complication
Examples:
- Pocket hematoma requiring evacuation
- Lead dislodgement requiring reposition
- Post-op bleeding requiring return to cath/EP lab
Modifier 79 – Unrelated procedure by the same provider
Examples:
- Pacemaker patient undergoes unrelated cath or PCI during global
- ICD patient receives venous ablation or carotid stenting during global
- The device patient undergoes a stress test + cardioversion for an unrelated arrhythmia
Special Cases: Staged PCI & Global Period Overlap
PCI has a 0-day global, but staged PCI interacts with device globals.
Example:
A patient receives a pacemaker (90-day).
Thirty days later, they undergo a planned PCI.
How to bill:
- PCI is unrelated to pacemaker surgery
- Use modifier 79 (unrelated procedure)
- Full PCI codes payable
If PCI was performed for a complication of device surgery (rare), 78 may apply.
Documentation Requirements for Global Period Accuracy
Documentation is the key to correct E/M coding during global periods.
Every cardiology note should include:
1. Relationship to recent procedure
Explicitly state:
- “Visit unrelated to pacemaker implantation on 10/05/25.”
- OR
- “Visit directly related to postoperative wound care.”
2. Why the visit is medically necessary
- Symptoms
- Diagnostic testing results
- Clinical decision-making
3. Chronic condition management
Avoid tying it to recent surgery unless it is directly relevant.
4. Diagnostic test interpretation
If performed globally, it must be fully interpreted and medically necessary.
5. Staged procedures
Plan must be written in:
- Original procedure note
- Follow-up notes
6. Complication documentation
Must describe:
- The problem that occurred
- Why was a return to the OR required
- What corrective action was performed
Auditors expect clear differentiation between:
- Routine post-op care (bundled)
- Complication care (78)
- Unrelated care (24/79)
- Staged additional work (58)
Common Errors and Audit Risks in Cardiology Global Periods
1. Billing routine follow-up visits
Pacemaker wound checks → bundled
ICD threshold checks (related to healing) → bundled
2. Billing E/M without modifier 24 for unrelated issues
Results in claim denials or audits.
3. Using modifier 25 incorrectly
Especially before cardioversion or minor EP procedures.
4. Billing device interrogation as routine follow-up
Interrogation is billable, but routine healing checks are not.
5. Staged PCI billed without modifier 58
6. Complication return mislabeled with modifier 79 instead of 78
7. Billing diagnostic tests without medical necessity
Example:
- Echo ordered “post-device follow-up” without a clinical reason → risk of audit.
8. Not documenting the relationship to the recent procedure
The #1 reason modifiers get denied.
Best Practices for Cardiology Teams
Create a global period tracker.
- Automatically calculate 90-day windows
- Assign alerts for staged procedures
- Flag global conflicts during scheduling
Standardize documentation templates
Include:
- “Related or unrelated to recent procedure?”
- “Reason for diagnostic test?”
- “Is this visit routine post-op care?”
Train physicians on modifier usage.
Especially 24, 25, 57, 58, 78, 79.
Audit high-risk claims
- Pacemaker/ICD
- Device revisions
- EP ablations
- Staged PCI
- Return-to-OR procedures
- Visits within global windows
Maintain payer-specific global variations.
Some commercial payers alter global rules.
Conclusion
Cardiology global periods require precise modifier use, strong documentation, and clear separation between routine post-operative care and unrelated conditions. Misunderstanding these rules can result in significant denials, recoupments, or audit exposure. By implementing structured workflows, global tracking systems, and standardized documentation templates, practices can ensure accurate and compliant billing. Many cardiology groups collaborate with specialized RCM teams—such as Global Tech Billing LLC—to support accurate navigation of 0-day versus 90-day global rules.
FAQs
1. Do PCI procedures have a global period?
Most PCI procedures have a 0-day global, meaning post-procedure visits are billable.
2. Which cardiology procedures carry 90-day globals?
Pacemaker/ICD implants, generator changes, surgical vascular procedures, and epicardial lead surgeries.
3. Are routine post-op device checks billable?
Wound checks and healing assessments are bundled; device interrogations are usually separately billable.
4. When is modifier 24 used?
For unrelated E/M visits during a 90-day global period.
5. What modifier applies to staged PCI?
Modifier 58, used when the second intervention is planned or related but staged.
6. What modifier applies to complications requiring a return to the cath/EP lab?
Modifier 78.
7. Can diagnostic tests be billed during a global period?
Yes—echo, ECG, stress tests, Holter, and device interrogations are separately payable.
8. When is modifier 79 used?
When an unrelated procedure is performed during the global of another procedure.
