Chapter 12 – Surgery Guidelines and General Surgery
The Surgery Section is the largest in the CPT Manual. The codes range from the 10,000
section to the 90,000 section. Most surgery subsections are defined according to medical
specialty or body systems. This section is divided into 19 subsections.
Page 368 of SBS Textbook
Guidelines are located in the front of each section of the CPT book. These guidelines will help
you be able to correctly code the chart note, operative report, test, etc.
Note: CPT is updated once a year. January 1 of each year brings new changes, revisions,
deletions, etc. Be sure to review the guidelines for any of these changes. Changes are also
located in the appendices in the back of each book.
Page 369-370 of SBS Textbook
Notes may appear in each section, subsection, heading, subheading, and subcategories. They
give you special instructions that are particular to code or sets of codes.
Page 370 of SBS Textbook
Additional notes, revisions, deletions, or instructions may appear in parenthesis below the code.
Special Reports and Unlisted Procedures– page 371 and 372
Special Reports may need to be submitted for those procedure using an unlisted procedure.
The description of the service should list the nature, extent, and need for the procedure as well
as the time, effort, and equipment necessary to provide the service.
Surgical package? - pgs 374 – 378 of SBS Textbook
An example: When you go the bakery to buy a cake, you are not charged separately for the
sugar or the eggs needed to make that cake. The price you pay for that cake includes all the
ingredients. The same holds true for surgeries. There are certain parts of the surgeries that
are included in the service and are not billable to the insurance company.
Items included in the global surgical package? – Read the Guidelines in your CPT book. Also
note that there are some differences between CPT and CMS guidelines!!**
Per CPT:
 The operation itself and intraoperative care
 Local anesthesia
 One related E/M service subsequent to the decision for surgery.
 Writing orders
 Routine supplies (provided by the surgeon’s office)
 Evaluation of the patient in the post anesthesia recovery area
 Typical postoperative follow-up care – including usual complications - for a
designated number of days (global days) depending on the global period assigned
to the CPT code.
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Chapter 12 – Surgery Guidelines and General Surgery
Per CMS:
 The operation itself and intraoperative care
 Local and regional anesthesia
 One related E/M service subsequent to the decision for surgery.
 Writing orders
 All supplies (provided by the surgeon’s office)
 Evaluation of the patient in the post anesthesia recovery area
 All related postoperative follow-up care – including complications that do not
require a return to the operating room - for a designated number of days
depending on the global period assigned to the CPT code.
What are global days? Page 375 of SBS Textbook
Global days are the number of days after the surgery that the patient comes in to the doctor to
see how well he/she is healing. In coding language, this is known as global surgery period or
global days. Global day’s online calculator: http://askleslie.net/drup3/node/45
Many payors follow CMS (Medicare) guidelines for determining the number of global days.
The global period is usually 90 days for major procedures and 0 or 10 days for minor
procedures. NOTE: Some insurances will use 45 day post op periods also. Check with your
local carriers.
To determine the number of global days a particular procedure has (according to CMS), refer to
the National Physician Fee Schedule Relative Value File, which can be downloaded for free at
http://new.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage.
What if the patient returns for services during the global period?
First you must determine how many global days were associated with the procedure and what
kind of insurance they have. (Remember, not all insurances follow the CMS guidelines. You
should check each payor in your state).
o If a patient returns to the surgeon’s office for a routine postoperative follow-up
visit, including minor, expected/usual complications, you can not bill for this
service. It is included in the payment received for the surgery. You may track the
service using code 99024. This also applies to routine follow-up visits in the
hospital. No modifier is used on 99024.
o If a patient returns for an office or hospital visit due to unusual or unexpected
complications directly related to the procedure:
 For payors that follow CMS guidelines: You cannot bill separately
because all related postoperative follow-up care – including
complications that do not require a return to the operating room are
included.
 For all others: You should bill the office visit / LOS with a –24 modifier
(unrelated E/M service during post-op period).
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Chapter 12 – Surgery Guidelines and General Surgery
o If a patient returns for a minor procedure in the office due to minor
complications:
 For payors that follow CMS guidelines: You cannot bill separately
because all related postoperative follow-up care – including
complications that do not require a return to the operating room are
included.
 For all others: You should bill the procedure with a –79 Modifier (unrelated
E/M service during post-op period)
o If a patients returns to the office or hospital for an unrelated E/M service:
 Bill the office visit / LOS with modifier –24 (E/M service unrelated to the
original procedure)
o If a patient returns to the office or the operating room for an unrelated
procedure:
 Bill the procedure with a –79 modifier (unrelated procedure during the postop period)
 A new post-op period begins when using –79 modifier
o If a patient is returned to the operating room for a related procedure:
 Bill the procedure with a –78 modifier (Return to operating room for a
related procedure). A new post-op period does not begin.
o If a patient returns to office or operating room for a staged procedure
(planned) or a procedure that is more extensive than the original procedure:
 Bill the procedure with a –58 modifier (staged or related procedure).
 A new post-op period begins when using –58 modifier.
o Also review modifiers for additional surgeons who may have assisted in the
procedure. Modifiers include: 62, 66, 80, 81, 82
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Chapter 12 – Surgery Guidelines and General Surgery
Below are just some of the common policies found in the National Correct Coding Policy Manual
that you should be aware of.
 Coding based on standards of medical practice. Any activities that are
integral to a procedure are considered to be included in each surgical code.
Some examples of services that are integral to all codes are:
- Cleansing, shaving, and prepping of skin
- Draping, prepping and positioning of the patient
- Insertion of IV access for medication
- Anesthesia administered by the physician performing the procedure
- Surgical approach including: identification of anatomical landmarks,
incision & evaluation/exploration of surgical field, simple debridement
of traumatized tissue, lysis of simple adhesions and isolation of
structures that are limiting access to the surgical field.
- Wound irrigation and surgical cultures
- Insertion and removal of drains, suction devices, dressings and pumps
into same site
- Surgical closure
Generally, if a service is necessary to successfully accomplish a procedure and failure to
perform it would compromise the success of the procedure, it is considered to be an
integral part – bundled – and should not be billed separately.
Generally, when a lesser service is followed by a more extensive service on the same
anatomic location, only the more extensive service is reported. EXAMPLE: A lesion is
biopsied and then destroyed - bill only for the destruction because it is more extensive.
Page 378 of SBS Textbook
See General Subsection on page listed above.
Page 376 of SBS Textbook
Note: Depending on the state you are in, the supplies for the surgery will either be billed under
99070 or using the HCPCS book. For class purposes – 99070 is used for supplies.
Also – the post operative CPT is 99024. This is not billed to insurance, it is used for internal
informational and tracking purposes only and to help the coder determine when a service can be
billed or not billed. It also indicated the services were included in the global package. See
pages 376 – 377 in SBS Textbook.
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Chapter 12 – Surgery Guidelines and General Surgery
Tips for coding from the operative report:
 Copy the operative note so you can write or highlight any information that will help you
understand what is going on. Highlight any key words.
 As you read it, cross off any non-coding information. (Re-read it multiple times if
necessary!!!)
 Identify what was done and the approach used (e.g. was it open or laparoscopic?).
 Use the dictionary, anatomy books, and www.answers.com for unfamiliar terms.
Website for medical diagrams. Can also click on “Images” in the upper left hand
corner of www.google.com
 Code everything. Write all codes down on op note.
 If you can’t decide between a couple of codes, use the Coder’s Desk Reference and
compare the description to the op note
 Ask your fellow coders and the surgeon if necessary to explain items you don’t
understand.
 Check the NCCI edits and the National Correct Coding Policy Manual for bundling
issues and cross off any codes that can’t be billed separately.
http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp?listpage=1
 Review the patient’s record for insurance information – beware of any carrier-specific
guidelines, Medicare NCDs and LCDs. Carrier-specific websites can be found via the
internet. Also check the patient’s previous visits to see if the current service provided
occurred during the post-operative visit.
o National / Government Website: http://www.cms.hhs.gov/mcd/downloads.asp
o Local Website (ex. Minnesota)
http://www.wpsmedicare.com/part_b/policy/policy_active.shtml
 Check for possible modifier use. Modifiers are located on the front inside cover of your
CPT Book. Further explanation of each modifier is also located in Appendix A of the CPT
Book. Other resources are your coding companion, NCCI edits book which can be
purchased from various vendors, or Encoders from various vendors also.
 If there are multiple procedures, list all procedures codes starting with the
procedure with the highest RVU. The procedure with the lowest RVU should be
listed last. Check with your company to see how the provider is paid in RVU’s in order
to know which RVU Column to use. Most are either paid in “Work RVU’s”, “Total Facility
or Non-Facility.” RVU’s.
http://new.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage.
 Make sure you link a diagnosis with each procedure. You can use your coding
companion to help you determine which diagnosis (diagnoses) are payable with each
procedure(s). Also look at National and Local policies if available. Encoders and coding
companions will help you determine the correct diagnosis linkage to the procedure. See
below for sample page from a coding companion.
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