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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods 
that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 
000, 010, 090, and, sometimes, YYY. 
 
Codes with "090" in Field 16 are major surgeries. Codes with "000" or "010" are either minor surgical 
procedures or endoscopies. 
 
Codes with "YYY" are A/B MAC (B)-priced codes, for which A/B MACs (B) determine the global period (the 
global period for these codes will be 0, 10, or 90 days). Note that not all A/B MAC (B)-priced codes have a 
"YYY" global surgical indicator; sometimes the global period is specified. 
 
While codes with "ZZZ" are surgical codes, they are add-on codes that are always billed with another service. 
There is no postoperative work included in the fee schedule payment for the "ZZZ" codes. Payment is made for 
both the primary and the add-on codes, and the global period assigned is applied to the primary code. You can 
find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 12, Section 40.1. 
 
The rules say where physicians agree on the transfer of care during the global period, the following modifiers 
are used: 
 
"-54" for surgical care only; or 
"-55" for postoperative management only. 
 
Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate 
modifier. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 4.2 (A)(3). 
 
The rules say for surgeries performed January 1, 1992, and later, that are billed with either modifier "-54" or "-
55," A/B MACs (B) pay the appropriate percentage of the fee schedule payment. Fields 17-19 of the Medicare 
Physician's Fee Schedule (MPFS) list the appropriate percentages for pre-, intra-, and postoperative care of the 
total Relative Value Units (RVUs) for major surgical procedures and for minor surgeries with a postoperative 
period of 10 days. The intra-operative percentage includes postoperative hospital visits. 
 
Procedures with a "000" entry in Field 16 have an entry of "0.0000" in Fields 17-19. Split global care does not 
apply to these procedures. You can find this rule in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.4 (B). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.