You performed a bunionectomy three weeks ago. The patient comes back for a routine post-op check. You bill an E/M code. The claim gets denied. You wonder what went wrong when you documented everything correctly.

This scenario happens in podiatry practices every single day. Medicare’s improper payment rate for podiatry hit 11.2% in 2024, with $216.9 million in projected improper payments. Two of the biggest culprits? Global period violations and place-of-service (POS) code errors.

Understanding global periods and POS codes is essential to protect your practice revenue and avoid audits that can tie up thousands of dollars in held payments.

What Are Global Periods in Podiatry Billing?

Global periods are timeframes when all routine follow-up care is included in the original surgical payment. When you perform surgery with a global period, you can’t bill separately for related post-op visits.

The Three Types of Global Periods

  • 0-day global: No global period. Same-day services only included.
  • 10-day global (010): Includes the day of surgery plus 10 days of normal post-op care.
  • 90-day global (090): Includes the day of surgery plus 90 days of routine follow-up care.

Most podiatry surgeries fall into either the 10-day or 90-day category. Common procedures like bunionectomies, hammertoe corrections, and neuroma excisions typically have 90-day global periods. Simple procedures, such as nail avulsions, often have 10-day global effects.

What’s Included in the Global Period?

The global surgical package includes:

  • Pre-operative visits (usually the day before or the day of surgery)
  • The surgical procedure itself
  • Routine post-operative care
  • Complications that don’t require additional surgery
  • Pain management related to the surgery
  • Dressing changes at the surgical site
  • Removal of sutures or staples

What you CANNOT bill separately during the global period:

  • Routine follow-up visits to check healing
  • Expected post-op pain management
  • Normal wound care
  • Standard dressing changes
  • Evaluation of the surgical site

Why Global Period Claims Get Denied?

The denial reason usually says something like: “Service included in global surgical package” or “Payment adjustment, procedure performed during post-op period.”

Common Global Period Mistakes

  • Billing routine post-op visits: A patient had a bunionectomy 25 days ago. They come in for a scheduled follow-up. You bill 99213. The claim is denied because it’s within the 90-day global period.
  • Missing the right modifier: A different patient comes in 30 days post-bunionectomy with cellulitis on the opposite foot. You bill an E/M code without modifier 24. The claim denies, even though the visit was unrelated.
  • Not documenting new problems clearly: The patient had toe surgery 3 weeks ago, but now has a new ulcer on a different toe. Your notes say “post-op visit.” The claim is denied because the documentation doesn’t show it’s a separate problem.
  • Using wrong codes for complications: A surgical site opens up and requires resuturing. You bill the repair code without modifier 78. The claim is denied or processed at a reduced rate.
Situation What Happens Correct Action Modifier Needed
Routine post-op visit Included in the global, no separate payment Don’t bill E/M or use CPT 99024 None (or 99024 for tracking)
Unrelated E/M during global Can be billed separately Bill E/M with a different diagnosis Modifier 24
Complication requiring return to OR Can be billed separately at a reduced rate Bill procedure code Modifier 78
Unrelated surgery during global Can be billed at full value Bill’s new procedure Modifier 79
Related E/M on the same day as the procedure Can be billed if significant Bill E/M with procedure Modifier 25

How to Bill Correctly During Global Periods?

Success with global periods comes down to documentation and modifiers.

Using CPT 99024 for Tracking

CPT 99024 is a reporting code for routine post-op care. It generates no payment but tells Medicare you saw the patient. CMS requires 99024 reporting to accurately track post-op visits.

Why report 99024? CMS uses this data to evaluate whether global packages should be redesigned. Missing 99024 reports can trigger audits and payment holds.

Modifier 24: Unrelated E/M During Global

Use modifier 24 when you provide an E/M service during the global period for a problem completely unrelated to the surgery.

Example: Patient had a bunionectomy 2 weeks ago. Comes in today with an ankle sprain on the opposite foot. Bill the E/M with modifier 24 and link it to the ankle sprain diagnosis, NOT the bunionectomy diagnosis.

Critical documentation: Your notes must clearly state that it is “unrelated to recent surgery.” Specify the new problem’s location and cause. Don’t mention the surgical site unless you’re also addressing it.

Modifier 78: Return to OR for Complication

Use modifier 78 when the patient needs to go back to the operating room during the global period for a complication of the original surgery.

The procedure is charged at a reduced rate (usually around 70-80% of the normal fee) because the global period has already been paid.

Example: Patient had hammertoe repair 30 days ago. Pin backs out and needs to be repositioned under anesthesia. Bill the pin repositioning code with modifier 78.

Modifier 79: Unrelated Procedure During Global

Use modifier 79 for a new, unrelated procedure performed during another surgery’s global period.

Example: Patient had bunionectomy 40 days ago (90-day global). Now needs nail avulsion on a different toe for an ingrown nail. Bill the nail avulsion with modifier 79.

This modifier tells the payer it’s a completely different problem and deserves a separate payment.

Modifier 25: Significant E/M Same Day as Procedure

This modifier is for billing an E/M service on the same day as a procedure when the E/M was significant and separately identifiable.

Example: Patient comes in for routine nail debridement. During the visit, you also evaluate and manage their new diabetic ulcer, which requires detailed history, examination, and treatment planning beyond the nail care. Bill the E/M with modifier 25.

Warning: Don’t use modifier 25 to “force through” an E/M that’s really just the decision to perform the procedure. The E/M must be substantial and separately documented.

Understanding Place of Service Codes

Place of service codes are two-digit codes that tell insurance companies WHERE you provided the service. Getting the POS code wrong causes immediate denials.

Common POS Codes for Podiatry

  • POS 11: Office
  • POS 22: Outpatient hospital
  • POS 24: Ambulatory surgical center
  • POS 31: Skilled nursing facility
  • POS 32: Nursing facility
  • POS 12: Patient’s home

Each POS code has different reimbursement rates. Office-based services (POS 11) typically pay higher than facility-based services because they include overhead costs.

Why POS Code Errors Cause Denials

  • Mismatched codes and locations: You bill POS 11 for a service performed at a hospital outpatient department. The claim was processed but is later audited. The insurance company takes back the overpayment.
  • Wrong facility vs. office coding: You perform a procedure in your office surgical suite, but accidentally bill POS 24 (ASC). The claim pays at a reduced facility rate. You lose money.
  • Inconsistent coding patterns: You bill the same patient at POS 11 one week and at POS 22 the next, even though your office location hasn’t changed. This triggers fraud alerts.
  • Missing POS codes entirely: Some billing systems default to POS 11. If you actually saw the patient at a nursing home, the claim might be denied or processed incorrectly.

How POS Codes Affect Reimbursement

Medicare pays different amounts based on POS codes. The fee schedule has two rates:

  • Non-facility rate: Higher payment for services in physician offices (POS 11, 12) where the provider supplies all equipment and overhead.
  • Facility rate: Lower payment for services in hospitals, ASCs, or SNFs (POS 22, 24, 31, 32) where the facility provides equipment and staff.

Using the wrong POS code doesn’t just cause denials; it can also lead to other issues. It can result in incorrect payment that must be refunded later.

CMS Increased Scrutiny in 2025

CMS enhanced auditing in 2025 to more closely monitor global period billing.

What They’re Looking For

  • Automated cross-matching: Claims systems automatically compare surgical dates with E/M visits. Services during global periods get flagged for review.
  • Missing 99024 reports: Practices not reporting routine post-op visits with 99024 face audit letters asking why no follow-up care was documented.
  • Excessive use of modifier 24: Billing many unrelated E/M codes during global periods triggers review. They want to see if these visits are truly unrelated.
  • Modifier 25 overuse: Claims with modifier 25 on every procedure visit get scrutinized. They check if the E/M services were actually significant and separately identifiable.

Audit Triggers

  • Multiple E/M codes with modifier 24 during one global period
  • No 99024 reporting for high-volume surgical practices
  • POS code variations for the same patient without a clear reason
  • High percentage of modifier 25 usage compared to peer practices

Preventing Global Period and POS Denials

Build systems that catch these errors before claims go out.

Pre-Claim Checks

  • Global period tracking: Use billing software that flags when a patient has an active global period. Alert staff before scheduling E/M visits.
  • POS code verification: Before submitting claims, verify the service location matches the POS code. Create a checklist for staff.
  • Modifier requirements: Set up automatic prompts asking: “Is this visit unrelated to recent surgery?” If yes, add modifier 24.
  • Documentation templates: Create visit note templates that prompt providers to indicate whether the visit is related to or unrelated to previous procedures.

Staff Training

Train your front desk, clinical staff, and billing team on:

  • What global periods are and why they matter
  • How to identify when a patient is in a global period
  • Proper POS code selection based on service location
  • Which modifiers to use in different scenarios
  • Documentation requirements for billing during globals

Regular Audits

Practices with quarterly internal audits saw 17% fewer denials than those with annual audits. Review:

  • Global period claims: Pull all E/M codes billed during global periods. Verify modifier 24 usage and documentation.
  • POS code accuracy: Compare POS codes to actual service locations. Look for patterns of errors.
  • Modifier usage: Check that modifiers 24, 25, 78, and 79 are used correctly based on documentation.
  • 99024 reporting: Ensure routine post-op visits are tracked with 99024.

Documentation Best Practices

Good documentation is your best defense against denials and audits.

For Services During Global Periods

When billing any service during a global period, your notes must include:

  • Statement of relationship to surgery: “Visit today is unrelated to the bunionectomy performed on [date]” OR “Patient returns for routine post-op care after surgery on [date].”
  • New problem documentation: Describe the new issue in detail. State location, symptoms, onset, and why it’s separate from the surgical problem.
  • Different diagnosis codes: Link the E/M to a diagnosis completely different from the surgical diagnosis.
  • Medical necessity: Explain why the patient needed to be seen, especially if during a global period.

For POS Code Accuracy

Every visit note should document:

  • Exact location where service was provided
  • If at a facility, note the facility name
  • For home visits, note it was at the patient’s residence
  • For office visits, confirm it was at your office location

This documentation supports your POS code selection if questioned later.

Get Expert Help With Podiatry Billing

Managing global periods, POS codes, modifiers, and documentation requirements can overwhelm even experienced podiatry practices. Between seeing patients and running your practice, billing complexities can pull your focus away from patient care.

At West Virginia Medical Billing, we specialize in podiatry billing and understand the unique challenges you face with global periods and POS coding. Our expert team ensures every claim is submitted the first time.

Stop losing money to global period denials and POS code errors. Let our podiatry billing experts handle the complexity while you focus on treating patients. Contact us today for a free practice assessment

Frequently Asked Questions

What happens if I bill an E/M during a global period without modifier 24?

The claim will likely be denied as “service included in the global period.” Add modifier 24 with documentation to appeal or bill the first time.

Can I bill for complications that happen during the global period?

Yes, if the complication requires a return to the OR (use modifier 78) or is a new problem needing significant E/M work (use modifier 24). Routine post-op issues, such as mild pain, are included in the global package.

How do I know which global period applies to a procedure?

Check the Medicare Physician Fee Schedule or your billing software for the CPT code’s global period. Major surgeries often have a 90-day waiting period, while minor procedures usually have a 10-day waiting period.

What if the patient’s insurance has different POS requirements than Medicare?

Always follow the payer’s specific POS rules, as commercial insurers may differ from Medicare. Call the insurer to confirm accepted codes before submitting claims.

Do I need to use CPT 99024 for every routine post-op visit?

Yes, CMS requires 99024 to track post-op care within global periods. Even though it pays nothing, proper reporting helps avoid audits and ensures complete documentation.