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Billing and Coding Guidelines for General Surgery

Billing and Coding guidelines for General Surgery December 1, 2021

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

Surgery CPT Codes Description
20610DRAIN/INJECT, JOINT/BURSA
29581APPLY MULTLAY COMPRS LWR LEG
29125APPLY FOREARM SPLINT
29515APPLICATION LOWER LEG SPLINT
20552INJ TRIGGER POINT, 1/2 MUSCL
29105APPLY LONG ARM SPLINT
29881KNEE ARTHROSCOPY/SURGERY
20680REMOVAL OF SUPPORT IMPLANT
29126APPLY FOREARM SPLINT
23430REPAIR BICEPS TENDO
25605TREAT FRACTURE RADIUS/ULNA
23650TREAT SHOULDER DISLOCATION
23350INJECTION FOR SHOULDER X-RAY
20553INJECT TRIGGER POINTS, =/> 3
29826SHOULDER ARTHROSCOPY/SURGERY
29877 KNEE ARTHROSCOPY/SURGERY
26055 INCISE FINGER TENDON SHEATH
20605 DRAIN/INJECT, JOINT/BURSA
29823 SHOULDER ARTHROSCOPY/SURGERY
22513PERQ VERTEBRAL AUGMENTATION
29824 SHOULDER ARTHROSCOPY/SURGERY
26010DRAINAGE OF FINGER ABSCESS
24640TREAT ELBOW DISLOCATION
29882KNEE ARTHROSCOPY/SURGERY
28485TREAT METATARSAL FRACTURE
27096INJECT SACROILIAC JOINT
29505APPLICATION, LONG LEG SPLINT
28291CORRJ HALLUX RIGIDUS W/IMPLT
26605TREAT METACARPAL FRACTURE
23515TREAT CLAVICLE FRACTURE
28285 REPAIR OF HAMMERTOE
22514PERQ VERTEBRAL AUGMENTATION
29888 KNEE ARTHROSCOPY/SURGERY
27792TREATMENT OF ANKLE FRACTURE
27093INJECTION FOR HIP X-RAY
25608TREAT FX RAD INTRA-ARTICULAR
27570FIXATION OF KNEE JOINT
29822SHOULDER ARTHROSCOPY/SURGERY
27447TOTAL KNEE ARTHROPLASTY
29806 SHOULDER ARTHROSCOPY/SURGERY
25565 TREAT FRACTURE RADIUS ULNA
25607TREAT FX RAD EXTRA-ARTICUL
25115REMOVE WRIST/FOREARM LESION
26770 TREAT FINGER DISLOCATION

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:

CodeDescriptions
19357

Tissue expander placement in breast reconstruction, including subsequent expansion(s)(previously stated breast reconstruction, immediate or delayed, including subsequent expansion)   The subsequent expansions of the tissue expander are included in code 19357.
19361

Breast reconstruction; with latissimus dorsi flap (had said the same plus “without prosthetic implant”)    The extensive notes for this code explain what not to report.  If there is the insertion of an implant in addition to latissimus dorsi flap on the same day, additionally code 19340 to 19361. If it is on a separate day, use 19342.

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:

CodeDescriptions
19370

Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy (had stated open periprosthetic capsulotomy, breast)  
In most cases, this is done to fix a displacement of an implant.
19371



Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (had stated open periprosthetic capsulectomy, breast)  Complete capsulectomy with implant removal is the key here. This was added for clarity. A partial capsulectomy is 19370. Physicians must document clearly.(Do not report 19371 with 19328, 19330, or 19370 in the same breast.  For removal and replacement with a new implant, use 19342)
19380



Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction (had stated revision of reconstructed breast).   In terms of revisions, this code description has been revised extensively. There is a full listing of codes not to report this within the CPT tabular, so coders must refer to it.

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

CodeDescriptions
30468


Unique, and was created to explain the repair of a nasal valve collapse with subcutaneous or submucosal lateral wall implants.
Furthermore, a code was also required to recognize the opening of the nasal collapse using minimally invasive methods and absorbable lateral wall implants.
30468
Report for a bilateral system
Add modifier 52 to the process if it is performed unilaterally.

Respiratory System: The Lungs and Pleura

Code
32408



For 2021, to report core needle biopsy of the lung or mediastinum using all imaging guidance types, including, but not restricted to, CT, MRI, ultrasound, and fluoroscopy.
The current guidelines for 32408 state that imaging guidance is not to be listed separately, and the code is only used once per lesion tested in a single session. If multiple lesions are tested on a corresponding day, select 32408 for each lesion examined simultaneously, including modifier 59.

Male Genital System: Prostate

CodeDescription
55880
Code is used to report transrectal, high-intensity-focused ultrasound (HIFU) guided ablation of malignant prostate tissue.

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

Female Genital System: The Cervix Uteri

CodeDescription
57465A unique add-on code generated to report computer-aided colposcopy to assist in the cervix’s biopsy.
57465
Used in combination with vaginal colposcopy procedures (57420, 57421) and cervical colposcopy procedures (57452-57461).
57465
The specification states that it combines optical dynamic spectral imaging that aids in the mapping of abnormal measures for biopsy.

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. 

CodeDescription
CPT
69705
Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); unilateral (effective 1/1/2021)
69706
Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); bilateral (effective 1/1/2021)
69799
Unlisted procedure, middle ear HCPCS C9745 Nasal endoscopy, surgical; balloon dilation of the eustachian tube 

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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