Cardiology is one of the most complex specialties when it comes to global surgical periods, because many cardiology procedures—particularly percutaneous ones—carry 0-day globals, while device implants and certain vascular surgeries carry 90-day global periods.
Incorrect billing during global periods remains a top audit trigger for Medicare, Medicaid, and commercial payers. This guide provides a complete overview of global periods, covered services, non-covered services, modifier rules, documentation requirements, and common denial risks in both interventional and electrophysiology cardiology.
Understanding Global Surgical Periods in Cardiology
Every procedure assigned a global period includes a specific set of services bundled into the payment. Global periods are classified as:
000 – 0-Day Global
- No preoperative or postoperative days included.
- Payment only covers the procedure itself.
- Evaluation and management services on the same day may be bundled.
Most percutaneous cardiology procedures fall under this category.
010 – 10-Day Global
- Rare in cardiology.
- Applies mostly to minor surgical procedures requiring short follow-up.
090 – 90-Day Global
- Major cardiology surgeries and device implants fall here.
- Includes:
- 1-day preoperative period
- Day of surgery
- 90 postoperative days
These procedures have the most billing restrictions.
Cardiovascular Procedures With 0-Day Global Periods
Most diagnostic and percutaneous (interventional) cardiology procedures have 0-day global periods, including:
Percutaneous Coronary Interventions (PCI)
- Angioplasty (92920/92921)
- Stent placement (92928/92929)
- Atherectomy (92924/92925)
- Chronic total occlusion PCI (92943)
Diagnostic Heart Catheterizations
- Left heart cath (93452)
- Right heart cath (93451)
- Combined (93453–93461)
FFR, IVUS, OCT
- 93571–93572 (FFR)
- 92978–92979 (IVUS)
- 92941–92944 (OCT/intravascular imaging)
Peripheral Vascular Interventions (PVI)
- Iliac: 37220–37223
- Fem-pop: 37224–37227
- Tibial-peroneal: 37228–37235
- Mechanical thrombectomy
- Atherectomy
- Stent placement
EP Diagnostic Studies
- 93600–93662 series (depending on complexity)
For 0-day global procedures, subsequent E/M visits are generally billable, unless they occur on the same day as the procedure and are not considered significantly separate.
Cardiovascular Procedures With 90-Day Global Periods
Long global periods apply to procedures involving permanent implants, open vascular surgeries, and major electrophysiology interventions.
Pacemaker & ICD Procedures
- Pacemaker insertion (33206–33208)
- ICD insertion (33249)
- CRT-P and CRT-D implants
- Surgical lead implantation or revision
- Generator replacement (33227–33229, 33262–33264)
Surgical Vascular Procedures
- Open femoral endarterectomy
- Open abdominal aortic repair
- Bypass grafts
- Open thrombectomies (34201–34203)
Ablation Procedures (some carriers treat as 90-day)
Although technically 0-day under CPT, many payers—especially Medicare Advantage—treat major ablation procedures as extended global care due to complexity and post-op expectations.
Examples:
- Atrial fibrillation ablation (93656)
- SVT ablation (93653)
- VT ablation (93654)
Always confirm payer-specific rules because global assignments can vary.
What Services Are Included in the Global Period?
The global surgical package includes the following:
1. Preoperative Care
- History & physical
- Pre-op risk assessment
- Surgical decision visit (for 90-day procedures, unless coded with modifier 57)
2. Day of Procedure Services
- Local anesthesia
- Immediate postoperative care
- Standard post-procedure monitoring
- Typical closure services
- Intraoperative supplies (bundled)
3. Postoperative Care (90-day procedures)
- Routine follow-up visits
- Dressing changes and wound checks
- Incision care
- Device checks directly related to healing or function
- Pain management is related to the procedure
- Management of post-op complications in the office
- But not return to the OR
Important:
The global surgical package does NOT include:
- Diagnostic tests
- Unrelated E/M services
- Services for unrelated new problems
- Return to the operating/procedure room for complications
- Services performed by another specialty for unrelated issues
What Is NOT Included in the Global Period?
These services are separately billable even during a 90-day global:
1. E/M for Unrelated Condition
Use modifier 24 if during the post-op period:
- Atrial fibrillation workup after pacemaker insertion
- Chest pain unrelated to device implant
- Hypertension management
2. Decision for Major Surgery
Use modifier 57 when the E/M visit leads to a major 90-day procedure.
3. Diagnostic Testing
Always separately payable:
- ECG
- Echo
- Stress tests
- Device interrogation
- Nuclear imaging
- Holter / Extended ECG monitoring
- CT, MRI
4. Therapy for Non-Procedure-Related Complications
Examples:
- Pneumonia
- Acute kidney injury
- Heart failure exacerbation not caused by the implant
5. Return to OR for Complication
Use modifier 78 (unplanned return).
Required Modifiers During Global Periods
Correct use of modifiers is essential to avoid denials and audits.
Modifier 24 — Unrelated E/M During Post-Op Period
Use on E/M visits when:
- The problem is unrelated to the recent surgery
- Documentation clearly shows a new diagnosis or an unrelated condition
Modifier 25 — Significant, Separately Identifiable E/M on Same Day as a Procedure
Used when:
- E/M exceeds routine pre-op work
- Procedure is minor (0- or 10-day global)
Modifier 57 — Decision for Major Surgery
Use when:
- E/M leads to a 90-day global procedure
- The decision must happen before the surgery
Modifier 58 — Staged / Related Procedure
For planned/staged procedures during the global period.
Examples:
- Staged PCI for different coronary arteries
- Planned lead insertion after initial pacemaker implant
- Staged vascular intervention based on initial cath findings
Modifier 78 — Return to OR for Related Complication
Examples:
- Lead dislodgement requiring revision
- Pocket hematoma evacuation
- Reoperation due to bleeding
Modifier 79 — Unrelated Procedure During Global Period
Used when:
- The procedure is unrelated to the initial surgery
- Example: ICD patient undergoes venous ablation in the same 90-day window
Cardiology-Specific Global Period Scenarios
Scenario 1: Post-Pacemaker Visit (Day 10)
Patient complains of fatigue → Echo ordered
- Echo = billable
- Visit may be billable with modifier 24 IF unrelated to surgery
- If related to healing/wound/pacing threshold → bundled
Scenario 2: Chest Pain After PCI
PCI = 0-day global → Visit is fully billable
No modifier needed.
Scenario 3: Staged PCI Protocol
Day 1: LAD stent
Day 30: RCA lesion treated
→ Bill RCA PCI with modifier 58 (staged).
Scenario 4: Lead Dislodgement After ICD Implant
Return to EP lab for revision within 90 days → use modifier 78.
Scenario 5: Hospitalization During Global Period for Unrelated Condition
HF exacerbation after pacemaker placement → bill normally with modifier 24 on E/M.
Common Global Period Billing Errors (All High-Audit Triggers)
Error 1: Billing routine post-op visits with 99212–99215
Routine visits are bundled.
Error 2: Charging diagnostic cath as part of staged PCI
Staged PCI requires:
- Documentation showing intent
- Different lesion/vessel
- Not simply re-evaluating the initial PCI
Error 3: Using modifier 24 on visits related to healing
Modifier 24 is only for unrelated conditions.
Error 4: Misuse of Modifier 25 in the Cath Lab
Payers scrutinize E/M + procedure same-day claims.
Error 5: Treating ICD and pacemaker generator changes as 0-day procedures
They carry 90-day globals.
Error 6: Coding unrelated procedures without modifier 79
Example:
- Ablation during the global period of pacemaker replacement
- This must include modifier 79 to avoid global denial.
Documentation Requirements for Global Period Billing
For any billable E/M or procedure during a global period, documentation must clearly state:
1. Whether the issue is related or unrelated
Include specific statements such as:
“Symptoms unrelated to pacemaker insertion performed on 10/02/2025.”
2. Why is diagnostic testing medically necessary
Testing must be justified, especially in the post-op period.
3. Clear linkage to diagnoses
Diagnoses must match global period modifier usage.
4. For staged procedures:
- Written plan
- Lesion/vessel details
- Rationale for staging
5. For complications requiring re-intervention:
- Description of event
- Need for return to OR
- Details of the procedure performed
Clear documentation differentiates related postoperative care (bundled) from unrelated conditions (billable).
Global Period Best Practices for Cardiology Groups
1. Maintain a Global Procedure Tracker
Track:
- Date of implant/procedure
- Start and end of the global
- Any planned staged interventions
2. Create Standard Templates
For:
- Device implants
- PCI documentation
- Staged PCI justification
- Complication notes
- Lead revision
- Wound care vs unrelated post-op symptoms
3. Educate Providers on Modifier Use
Especially 24, 25, 57, 58, 78, 79.
4. Conduct Internal Audits
Focus on:
- Pacemaker/ICD claims
- Staged PCI
- EP ablations
- Repeat vascular interventions
5. Validate Prior Authorization
Especially important for staged procedures occurring during global windows.
Conclusion
Understanding global period billing is essential for cardiology practices because incorrect use of modifiers, poor documentation, or misunderstanding of what is (and isn’t) included in the global package is a major source of recoupments and audits. Establishing clear workflows, global trackers, documentation templates, and internal review processes helps ensure compliance. Many practices work with specialized RCM partners, such as Global Tech Billing LLC, to maintain audit-ready cardiology billing systems.
FAQs
1. Do PCI procedures have a global period?
Most PCI procedures have a 0-day global, meaning post-procedure visits are usually billable.
2. Which cardiology procedures have 90-day global periods?
Pacemaker/ICD implants, generator changes, and surgical vascular procedures.
3. Are post-op device checks included in the global period?
Basic wound/device checks related to healing are bundled; diagnostic interrogations are usually billable.
4. When should modifier 24 be used?
For unrelated E/M visits during a 90-day global period.
5. What modifier applies to staged PCI?
Modifier 58 for planned staged interventions.
6. Which modifier is used for complications requiring return to the OR?
Modifier 78.
7. What is bundled in the global surgical package?
Routine post-op care, wound care, and procedure-related follow-up.
8. Are diagnostic tests included in the global period?
No. ECG, echo, stress tests, and nuclear studies are separately billable.
