Coding Guidelines For General Surgery Billing Services - Info Hub Consultancy
General Surgery Billing Services

Coding Guidelines For General Surgery Billing Services

What is General Surgery?

Surgery that targets the esophagus, stomach, small and large intestines, liver, pancreas, gallbladder, appendix, bile ducts, thyroid gland, and other organs is known as general surgery. Billers and coders for general surgery must be knowledgeable of the codes and terminology used in the field.

The advancement of cutting-edge technology that makes it possible for general surgeons to undertake complex surgeries also necessitates that they continually study and upgrade to stay current, leaving little or very little time for general surgeons to concentrate on medical billing and reimbursements.


 Coding Guidelines

It is important to be thorough with coding guidelines for general surgery in order to be rightly reimbursed for the services rendered.

Read on to know a few guidelines so you don’t lose money on the table. 

  1. Vascular and/or airway access are necessary for many invasive procedures. Pre-procedure or intra-procedure work includes the work necessary to secure the required access. The post-procedure work includes the tasks necessary to get a patient back to the proper post-procedure state.
  2. The endoscopic procedure is not separately reportable from the non-endoscopic surgery if it is carried out concurrently with it to make sure that no intraoperative injuries occurred or to confirm that the procedure was done appropriately.
  3. An operative procedure includes exposure to and investigation of the surgical field, which is not reportable independently. The existing protocols may typically be recorded separately if further research into a surgical area leads to additional surgeries beyond the main treatment. However, an operation that the CPT code descriptor identifies as a “separate procedure” is not separately reportable if it is carried out through the same skin incision, orifice, or surgical approach in a location that is anatomically connected to the other procedure(s).
  4. The incision and opening of the organ are both included in an excision and removal. It is prohibited to report an HCPCS/CPT code for a -otomy procedure alongside a -ectomy code for the same organ.
  5. Multiple methods of doing the same task are incompatible and should not be reported individually.
  6. Only the finished procedure may be provided if a procedure using one technique fails and is changed to a procedure using a different approach.

General Guidelines to Ensure Your Coding Is Accurate

The first step is to review the header of the report. Followed by reviewing the CPT codebook and it is always advisable to start with the index. Then comes a slightly tedious part which is checking if the documentation is in place. This must be followed by making a preliminary code selection.

Once the selection is done, there are certain guidelines given for the codes which must be reviewed. You can eliminate any extras by reviewing the policies and can add any modifier required. The steps mentioned above will help the coder to deliver a neat operative report with correct coding.


Avoid Duplicate Billing

It is not uncommon for medical surgeons to perform multiple procedures during a single surgery. There are also times when the procedures, which are scheduled are changed during the surgery. In such scenarios, cases of duplicate billing are not uncommon. Since medical billers do perform a lot of coding, mistakes due to human error are bound to happen. That is why when medical facilities outsource procedures to a medical billing company or a medical billing agency, they can access the expert level knowledge of the staff and avoid such errors.


Audits and QC

Repetition of errors in general surgery coding specially is quite high. One way to avoid this from happening is to undertake several and regular quality checks accompanied by audits performed frequently. This reduces any denials and rejection of claims, thus keeping the revenue cycle in a good shape.



While coders are generally advised and well aware that their work is quite detail oriented, a single error can have a direct impact on the financial health of the medical facility. In such cases, maintaining a practice management software with required entries is advisable. Such entries must match with diagnosis and codes of procedures done by the surgeon.

At ICS, we house a team to expert medical billing professionals who understand the nuances of General Surgery billing services. Our team is well versed in latest updates taking place in medical billing arena ensuring we provide excellent services to the providers we work with.