Billing and Coding Guidelines for General SurgeryDecember 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|
|29581||APPLY MULTLAY COMPRS LWR LEG|
|29125||APPLY FOREARM SPLINT|
|29515||APPLICATION LOWER LEG SPLINT|
|20552||INJ TRIGGER POINT, 1/2 MUSCL|
|29105||APPLY LONG ARM SPLINT|
|20680||REMOVAL OF SUPPORT IMPLANT|
|29126||APPLY FOREARM SPLINT|
|23430||REPAIR BICEPS TENDO|
|25605||TREAT FRACTURE RADIUS/ULNA|
|23650||TREAT SHOULDER DISLOCATION|
|23350||INJECTION FOR SHOULDER X-RAY|
|20553||INJECT TRIGGER POINTS, =/> 3|
|26055||INCISE FINGER TENDON SHEATH|
|22513||PERQ VERTEBRAL AUGMENTATION|
|26010||DRAINAGE OF FINGER ABSCESS|
|24640||TREAT ELBOW DISLOCATION|
|28485||TREAT METATARSAL FRACTURE|
|27096||INJECT SACROILIAC JOINT|
|29505||APPLICATION, LONG LEG SPLINT|
|28291||CORRJ HALLUX RIGIDUS W/IMPLT|
|26605||TREAT METACARPAL FRACTURE|
|23515||TREAT CLAVICLE FRACTURE|
|28285||REPAIR OF HAMMERTOE|
|22514||PERQ VERTEBRAL AUGMENTATION|
|27792||TREATMENT OF ANKLE FRACTURE|
|27093||INJECTION FOR HIP X-RAY|
|25608||TREAT FX RAD INTRA-ARTICULAR|
|27570||FIXATION OF KNEE JOINT|
|27447||TOTAL KNEE ARTHROPLASTY|
|25565||TREAT FRACTURE RADIUS ULNA|
|25607||TREAT FX RAD EXTRA-ARTICUL|
|25115||REMOVE 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.
The following code descriptions were updated:
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.
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:
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.
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)
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
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.
Report for a bilateral system
Add modifier 52 to the process if it is performed unilaterally.
Respiratory System: The Lungs and Pleura
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
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
|57465–||A unique add-on code generated to report computer-aided colposcopy to assist in the cervix’s biopsy.|
Used in combination with vaginal colposcopy procedures (57420, 57421) and cervical colposcopy procedures (57452-57461).
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.
Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); unilateral (effective 1/1/2021)
Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); bilateral (effective 1/1/2021)
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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