Coding Guidelines for General Surgery Billing Services
                     Coding Guidelines For General 
Surg e   r  y      B   i  l l  i n   g      S   e   r   v  i  c  es
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.
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 Coding Guidelines
• Vascular and/or airway access are necessary for many invasive 
procedures. Pre-pr o c  e d  u r e    o r   i n t r a  - p r o  c e  d u  r e   w  o  r k   i ncludes 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.
• 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.
• 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 
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(88th8)a t6 9is4 a-8n6a3to4mically connected to the other procedure(s).
  
General Guidelines to Ensure Your 
Co  d   i n    g    I  s    A    c  c   u   r  a   t  e    
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.
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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.
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Audits and QC
Repetition of errors in general surgery coding specially is quite high. One 
way to avoid this fro m    h a  p p  e  n i n g    i s   t o   u  n d  e r t a  k e   s  e v  e ral 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.
 
Upcoding
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. 
At Info Hub, 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.
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(888) 694-8634
  
About Us
We at Info Hub Cons u  l t a  n c  y    S e  r v  i c e  s   ( I C  S  ) ,   a          
leading medical billing company in India offer medical billing 
solutions to healthcare organizations, physicians, medical 
institutions, and groups. Our revenue management cycle helps 
in reducing operational expenses and increasing the overall 
revenue.
Info Hub Consultancy Services (ICS) was founded in 2010 and is 
now one of the leading service providers of highly motivated, 
certified coders, and billers in the US medical billing industry.
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C   o   n   t  a   c   t     U   s                   
Info Hub Consultancy (ICS) Services Pvt. Ltd.
Sf No 558/2, Udayampalyam Rd, 
Nava India, Coimbatore,
Tamil Nadu 641028
Tel:  +1 (888) 694-8634 / +91 829-745-6441 
Email - [email protected]
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