Medycoding

What is Surgery Coding in medical?

Surgery medical coding means converting surgical procedures performed by the doctor into CPT codes for billing and reimbursement. These codes describe what procedure was done and how complex it was.

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Code range for Surgery

The Surgery Section (10021–69990) covers:

• Integumentary (Skin)

• Musculoskeletal

• Respiratory

• Cardiovascular

• Digestive

• Urinary

• Male & Female Genital

• Maternity

• Endocrine

• Nervous System

• Eye & Ear

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​Types of Surgeons and the Surgeries

1. General Surgeon

Focus: Abdomen, breast, skin, soft tissues, hernias.
Common Surgeries:

• Appendectomy

• Gallbladder removal (Cholecystectomy)

• Hernia repair

• Breast lump removal / Mastectomy

• Lipoma excision

• Bowel surgery

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2. Orthopedic Surgeon

Focus: Bones, joints, ligaments, tendons, spine.
Common Surgeries:

• Fracture repair

• Knee replacement

• Hip replacement

• ACL reconstruction

• Spine decompression or fusion

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3. Urologist (Urologic Surgeon)

Focus: Urinary tract & male reproductive system.
Common Surgeries:

• TURP (Prostate resection)

• TURBT (Bladder tumor resection)

• Prostate biopsy

• Kidney stone removal

• Circumcision

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4. Gynecologic Surgeon

Focus: Female reproductive system.
Common Surgeries:

• Hysterectomy

• Dilation & Curettage (D&C)

• Ovarian cyst removal

• Myomectomy (Fibroid removal)

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5. Neurosurgeon

Focus: Brain, spine, nerves.
Common Surgeries:

• Brain tumor removal

• Spinal decompression

• Shunt placement

• Aneurysm repair

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6. ENT Surgeon (Otolaryngologist)

Focus: Ear, nose, throat, head & neck.
Common Surgeries:

• Tonsillectomy

• Septoplasty

• Thyroid surgery

• Sinus surgery

• Ear tube insertion

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7. Ophthalmic Surgeon

Focus: Eye surgeries.
Common Surgeries:

• Cataract surgery

• LASIK

• Retinal surgery

• Glaucoma procedures

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Global Surgery package

In medical coding, a surgical package (also called a global surgical package) refers to a collection of services related to a surgical procedure that are bundled together for billing purposes. 

The intent is to cover all aspects of care related to the surgery within a specific period, rather than billing each part of the care separately.

A typical surgical package includes:

1. Preoperative Visits: Appointments before the surgery for evaluations related to the procedure, usually within a day or two of surgery.

2. Intraoperative Services: The actual surgical procedure.

3. Postoperative Care: Follow-up visits related to the surgery, typically for a designated global period (e.g., 10, 30, or 90 days) depending on the type of surgery. This may include wound checks, managing complications, and general follow-up related to the surgical outcome.

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What are the service that are inclusive in surgical package ?

■ Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical) 

■ Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia 

■ Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals 

■ Writing orders 

■ Evaluating the patient in the postanesthesia recovery area 

■ Typical postoperative follow-up care

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What is seperate procedure ?

Some procedures in the CPT codebook have a designation of “separate procedure,” which indicates that these procedures are usually components of a larger procedure and cannot be charged independently if completed as part of that procedure.

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What is Unlisted service or procedure ? 

Unlisted service or procedure refers to procedures that may be provided and not listed in this edition of the CPT Code Book. Such services should be reported with the appropriate "Unlisted Procedure" code to indicate the service, with a separate identifying "Special Report."

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What are the services that is not Included in the Surgical Package?

Certain services related to the surgery are not included in the package, such as:

• Additional, unrelated surgeries during the global period

• Treatment for complications that require a return to the operating room.

• Some diagnostic tests and unrelated services (e.g., separate treatments for conditions unrelated to the surgery.

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What is NCCI edits ?

NCCI stand for National correct coding initiative. It is a system that helps ensure correct coding and prevent improper payment for medicare Part B claims. The NCCI has two type of edits

1. Procedure to procedure (PTP) edits

2. Medically Unlikely Edits (MUEs)

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