Billing and Coding Guidelines for General Surgery

Billing and coding for general surgery include a wide range of procedures, from gastrointestinal (GI) tract surgery, kidney, pancreas, liver, and thoracic and abdominal surgery to breast surgery and elective surgery. The coding and billing of general surgery can be challenging due to numerous guidelines. Moreover, the general surgeons in 2019 faced 135 changes to ICD-10 codes and more than 69 changes to CPT codes. 

The Health Common Procedure Coding (HCPCS) describes medical devices, supplies, products, and services and aids Medicare and other insurance companies in processing health claims. Physician billing companies should be up to date with all the latest changes in CPT, ICD, and HCPCS codes to submit accurate claims to payers. 

In this article, we’ll discuss billing and coding guidelines for general surgery.

CPT Codes 20000-29999: Top Surgical Procedures

Coding updates for Surgery Section 2021:

Integumentary System-Breast Repair and Reconstruction

In the breast repair and reconstruction subsection (19316-19499) of the Integumentary System, 15 codes were updated, and two were deleted (19324 and 19366) in 2021. Moreover, this subsection includes new instructions for each code and new fundamental guidelines for coders. 

Breast Reconstructions

The following code descriptions were updated:

Codes 19364-19369 cover breast reconstruction using different types of flaps, such as fTRAM, DIEP, SIEA, bi=pedicled TRAM, TRAM with and without separate microvascular anastomosis or “supercharging.” The supercharging procedure increases blood flow in TRAM flaps with marginal circulation to ensure flap survival. All of these procedures are the same as in 2020. The only difference is that they now all mention: “including the closure of donor sites.”  Of course, this is just part of the code. Notes before each code explain what each type of flap entails.

Revisions for Breast Procedures

In the past, coders found it difficult to distinguish between breast reconstruction and revision. The descriptions of the three codes were revised:

Indeed, the documentation of all breast procedures codes is crucial. It may be good to discuss with surgeons to review the changes above so the documentation needed for coders will be included in operative reports.

Thus, we encourage coders to use the Breast Reconstruction in CPT Action Plan and to look at photos of the various breast reconstruction techniques online. Visualizing these can sometimes make it easier to understand what should be done.

On the other hand, the guidelines clarify which reconstruction method should be used for each breast. Codes have been updated: mammary is now known as breast, and language has been added that indicates whether a breast implant was inserted simultaneously or after a significant mastectomy.

Respiratory System: The Nose

Respiratory System: The Lungs and Pleura

Male Genital System: Prostate

Before 2021, coders were following an unrecorded code to communicate that method.

Female Genital System: The Cervix Uteri

Auditory System—Other Procedures: 

There are new codes designed to practice the nasopharyngoscopy technique for the dilation of the eustachian tube. Eustachian tube balloon dilation (ETBD) is the name of this procedure. In the past, coders reported this procedure using unlisted code 69799 because no specific code was available. 

Notice: CPT codes, descriptions, and materials are the property of the American Medical Association (AMA). The Centers for Medicare and Medicaid Services (CMS) owns the copyright to HCPCS codes, descriptions, and materials.

Therefore, the following surgery coding guidelines 2021 have been updated recently. For more accurate billing and coding for general surgery, refer to this website.

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