General Surgery Medical Billing Services - Compare Quotes From Vetted Providers

Orders, indications, and consent

• The operative note should match the preoperative diagnosis, indication, and planned procedure.
• Document urgent vs elective status, failed conservative therapy, and any intraoperative findings that changed the plan.

Approach and extent drive code choice

• Open vs laparoscopic vs robotic approaches use different code families. Record trocar placement, conversions, and reasons for conversion.
• For resections, capture side, segment, levels, margins, and reconstruction method. For breast, hernia, and colorectal work, specify type, size, mesh use, and laterality.

Global periods affect E/M and returns to the OR

• Know the 0, 10, or 90 day global period for each CPT.
• Use modifiers correctly: 57 for the decision for major surgery, 25 for a significant E/M on the same day as a minor procedure, 24 for unrelated E/M during the global, 58 for staged or related procedures, 78 for unplanned return to the OR, and 79 for unrelated procedures during the global.

Endoscopy hierarchy and bundling

• GI endoscopy codes follow base plus biopsy plus therapeutic hierarchies. Do not unbundle when a higher valued code includes the lesser service.
• Document complete vs limited exams, landmarks reached, anastomoses, and all interventions such as biopsy, polypectomy technique, dilation, control of bleeding, or stent placement.

Intraoperative imaging and guidance

• Fluoro or ultrasound guidance is often bundled. Only bill separately when CPT allows and the report documents rationale, findings, and independent interpretation.

Assistant surgeon and co-surgery

• When allowed, use 80, 82, AS, or 62 for co-surgeons with separate, distinct operative work. Confirm payer policies and indicate each surgeon’s role in the note.

Implants, mesh, and biologics

• Record manufacturer, catalog number, lot, size, and site for mesh, staplers, biologic grafts, and fixation devices.
• In hospital outpatient settings, ensure HCPCS C-codes or device pass-through codes are captured per facility policy.

Wound, drains, and lysis of adhesions

• Document wound class, layers closed, and drain placement with type and purpose.
• Significant lysis of adhesions may be separately reportable when it increases work beyond typical. Describe location, severity, and time.

Critical care, postoperative management, and TPN

• Critical care minutes are separately billable when criteria are met and not part of the surgical package.
• Document daily postoperative E/M carefully. Routine follow-up within the global is not separately payable.
• For nutrition and lines, capture catheter site, imaging confirmation, and infusion plans.

Site of service, anesthesia, and ERAS protocols

• ASC vs hospital outpatient vs inpatient impacts allowable components and reimbursement.
• Coordinate with anesthesia for accurate ASA modifiers and start/stop times.
• ERAS pathways do not change coding, but supporting data can help defend medical necessity for multimodal analgesia or early discharge.

Modifiers that matter

• 25, 57 for same-day E/M with procedures and decision for surgery.
• 24 for unrelated E/M in the global.
• 58, 78, 79 for staged, return to OR, and unrelated procedures in the global.
• 51 for multiple procedures, 59 or appropriate X modifiers for distinct services when edits bundle procedures, 50 for bilateral, RT/LT for laterality.
• 52 for reduced services, 53 for discontinued procedures with reason.
• 62 for co-surgery, 80 or AS for assistants, 76/77 for repeat procedures.

Prior authorization and coverage nuances

• Many hernia repairs with mesh, bariatric procedures, and complex hepatobiliary or colorectal cases require prior authorization.
• Verify coverage criteria such as BMI thresholds, documented comorbidities, failed nonoperative care, and smoking cessation when required.

Keeping billing in-house can work well when you have a stable team, predictable volume, and the capacity to hire, train, and cover vacations or turnover. You retain tight control over workflows but you also carry the risk and cost of staffing, QA, software, and performance management.

Outsourcing shifts those burdens to a specialized team that brings SLAs, denial management, and scalable capacity. It’s often a fit when claim volume is growing, denials are creeping up, or leadership wants to redeploy staff to patient-facing work without sacrificing cash flow.