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.

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Coding Guidelines For General Surgery
Billing Services
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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3. Coding Guidelines
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• 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.
• 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
through the same skin incision, orifice, or surgical approach in a location that is
anatomically connected to the other procedure(s).

4. General Guidelines to Ensure Your Coding Is
Accurate
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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.

5. Avoid Duplicate Billing
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• 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.

6. Audits and QC
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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.
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. Such entries must match with diagnosis and codes of procedures
done by the surgeon.
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.

7. About Us
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Though there are several common benefits offered by offshore medical
billing companies, but choosing the right medical billing partner plays a
vital role. Info Hub is one of the leading offshore medical billing companies
in Coimbatore, India, with sophisticated infrastructure and skilled
manpower that is highly experienced in multiple aspects of medical billing
and coding, to support healthcare practices grow heights and develop
consistency in generating revenue.
If you are looking to outsource your medical billing and coding services to a
reliable outsourcing partner, Info Hub is your ideal choice. With more than a
decade experience in providing excellent medical billing and coding
services, Info Hub has earned high client value by building trust with its top-
notch services. For a quick appointment, make a call to +1-888-694-8634 /
+91-0422-4212455.

8. Contact Us
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Info Hub,
Sf No 558/2, Udayampalyam Rd, Nava
India,
Coimbatore,
Tamil Nadu 641028
Call Us: +91 829-745-6441
Email Us At: inquiry@infohubservices.com