This report presents findings from four analyses of claims data related to global surgical services conducted from September 2023 to September 2025: the extent to which post-operative visits included in the global surgical package are provided to patients, the types of services provided by post-op practitioners, within-practice specialization in the provision of post-operative care, and methods to split the valuation for global surgical services.

Quantitative and Policy Analyses Related to Medicare Global Surgical Services

Andrew W. Mulcahy, Stephanie Dellva, Alice Y. Kim, Cameron Klig, Asa Wilks, Joachim O. Hero

ResearchPublished Aug 19, 2026

Medicare has long valued and paid for surgical procedures using global surgical packages that reflect the time and work involved in the procedures themselves, as well as pre- and post-operative care over specified time frames known as global periods. The Centers for Medicare & Medicaid Services (CMS) collects data on the post-operative care furnished during global periods and has, over several years, sought public comment on approaches to use these data and other inputs to improve global surgical package valuation.

This report presents findings from four analyses of claims data related to global surgical services conducted from September 2023 to September 2025: (1) the extent to which post-operative visits included in the global surgical package are actually provided to patients, as determined by observed-to-expected (O/E) ratios; (2) the types of services provided during global periods by practitioners other than the operating surgeon; (3) within-practice specialization in the provision of post-operative care during evaluation and management (E&M) visits; and (4) alternative methods to split the valuation for global surgical services.

CMS has repeatedly committed to improving the accuracy of global service valuations, most recently in its 2026 Physician Fee Schedule (PFS) Final Rule. Given the magnitude and persistence of disconnects between real-world patterns of patient care and assumptions underlying the valuation of surgical procedures under the PFS, CMS will likely need to broadly revalue all global surgical services. The analyses presented in this report provide examples of how this broad revaluation can be data-driven, transparent, and revisited over time.

Key Takeaways

O/E post-operative visit ratios often do not align with CMS valuation assumptions

  • Of all the expected post-operative visits following procedures with 10-day global periods, only 1.8 percent were reported to CMS in 2024.
  • For major procedures with 90-day global periods, the O/E ratio was 28 percent for 2024 procedures, which was similar to prior-year ratios.

CMS effectively pays twice for post-operative visits billed separately by practitioners other than the operating surgeon

  • E&M services provided during global periods by practitioners who were not paid as part of the global surgical package were relatively common.
  • However, there is little evidence to suggest that these separately billed E&M visits were systematically related to post-operative care.

CMS would benefit from further analysis of how practices provide and bill for post-operative care

  • There is substantial variation in O/E ratios across practitioners within practices, suggesting some degree of specialization in post-operative care. These patterns varied by specialty, which suggests a diverse set of models for post-operative care delivery.

An alternative method for splitting the valuation of surgical work could bolster CMS policy

  • Approaches that split the valuation based on the Physician Time File produce highly variable and, at times, implausible results across procedures.
  • Using observed follow-up data (i.e., the number of post-operative visits actually provided to patients as reported to CMS) leads to less variation across procedures.
  • CMS’ expansion of the scope for transfer of care modifiers is a first step toward better establishing the contributions of surgeons and post-op practitioners in its global package valuation.

Recommendations

  • Overall, CMS should continue to adopt primarily data-driven approaches to determine the valuation splits rather than use approaches that are based primarily on assumptions or input from specialty societies.
  • CMS should work toward a broader revaluation of global surgical services in future rulemaking cycles. As a first step, CMS may want to consider unbundling all post-operative visits from minor procedures with 10-day global periods.
  • In a subsequent rulemaking year, CMS may want to propose broad revaluation of all procedures with 90-day global periods, implementing the data-driven revaluation approach outlined by RAND as a starting point and relying on the usual revaluation process to resolve large reductions in work relative value units.
  • Other approaches—such as a hybrid approach that retains a bundled, fixed number of post-operative visits for one or two types of procedures and work (accounting for post-operative care coordination) while allowing separate billing of other post-operative visits—also warrant investigation and consideration.
  • Increased reliance on data and greater transparency around what Medicare buys through the global surgical package are key to addressing the lack of reporting and other mechanisms to ensure that providers are delivering the care Medicare pays for with the single bundled payment.
  • Shifting toward data- rather than assumption-driven global surgery valuation requires complete and reliable input data. Medicare’s longer-term efforts should consider how alternative approaches to improving global surgery valuation can help generate reliable information describing the number and level of post-operative visits provided to beneficiaries.

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Mulcahy, Andrew W., Stephanie Dellva, Alice Y. Kim, Cameron Klig, Asa Wilks, and Joachim O. Hero, Quantitative and Policy Analyses Related to Medicare Global Surgical Services. Santa Monica, CA: RAND Corporation, 2026. https://www.rand.org/pubs/research_reports/RRA4720-1.html.
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This work was sponsored by the Centers for Medicare & Medicaid Services and conducted in the Financing and Organization Program of RAND Health.

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