Successful Surgical Coding


*agenda subject to change

7:00AM — 8:00AM

Check-in and Breakfast (provided)

8:00AM – 9:45AM

Definition Kick-off 

  • The basics: defining coding vs. reimbursement
  • Types of codes: primary, add-on, Category III
  • What is a separate procedure per CPT?

The Global Surgical Package

  • What’s included in the global package, and what can be separately reported?
  • Deconstructing the global payment: surgical splits, RVUs. and physician time

Surgeon Role Modifiers

  • Co-surgery vs. assistant: Are you reporting these correctly?
  • Payor expectations for co-surgery and assistant surgery documentation
  • Reimbursement: difference between co- and assistant surgeon

Same-Day Procedure Modifiers

  • Modifier 22: What justifies modifier 22? and how to increase your chances of payment
  • Modifier 50: Which procedures accept a bilateral modifier?
  • Modifier 51 vs. 59: How do you know which one to use? How does reimbursement differ for each?
  • Modifier 52 vs. 53: What is the difference, and how are they used in general surgery?

Modifiers for Additional Procedures Performed During the Global Surgical Period

  • Modifier 58: Documenting staged procedures: Do they always need to be preplanned? What about repeating a resection after pathology shows more margins?
  • Modifier 79: What defines an unrelated procedure? Is a different diagnosis essential?
  • Modifier 78: Does this apply to in-office procedures? How do I report in-office treatment of postoperative complications?

Revenue Optimization; Charge Entry Tips of the Trade

Strategic Appeals: What to Do If You Hit a Brick Wall NEW!

Documentation for Unlisted Procedures

  • How to report and get paid
  • Template letter for reporting unlisted codes
  • Case scenarios

9:45AM – 10:00AM


10:00AM — 12:00PM

Surgical Coding and Documentation

Radiology Coding and Documentation for Surgeons

  • Fluoroscopy and ultrasound: Is a separate report required? What about intra-operative imaging?
  • Documenting imaging with central lines: fluoroscopy, ultrasound, or both?

Surgical Approaches and Code Selection; Percutaneous vs. Open vs. Laparoscopic – Does it Matter?

Coding for Robotic Assistance NEW!

  • Using the HCPCS code
  • Setting a fee and getting paid

Operative Note Documentation Best Practice Op Note Format NEW!

  • Documentation to optimize coding accuracy and revenue

Hernia Surgery

  • Hiatal/paraesophageal hernias: Type 1, 2, 3, 4.
  • Open/laparoscopic hernia repair
  • Reporting mother procedures with hernias codes – CPT rules vs. payor realities
  • Reporting mesh placement
  • Reporting mesh removal; infected and non-infected mesh
  • Component separation release/abdominal reconstruction
  • Case scenarios

Abdominal Reconstruction/Component Separation

  • Documentation imperatives
  • Myocutanoeus flaps vs. Rives Stoppa

All About Implants

  • Biological vs. non-biological: knowing which to report

12:00PM — 1:00PM

Lunch (provided)

1:00PM — 2:00PM

Procedure Coding (continued)

Endoscopy Overview

  • General concepts in endoscopy coding; completion endoscopy – billable or not?
  • Moderate sedation: are you documenting enough?
  • Upper GI endoscopy overview
  • Colonoscopy: sigmoidoscopy vs. colonoscopy: How far is far enough?
  • Case scenarios

Colorectal Surgery

  • Approach matters: laparoscopic vs. open vs. robotic
  • What’s the difference between colostomy and coloproctostomy? A sigmoid colectomy and a low pelvic anastomosis?
  • Total and subtotal colectomy; Is there a difference?
  • Stoma creation, revision, and closure
  • Case scenarios

Appendix Surgery

  • Lap vs. Open
  • Laparoscopic repair of a ruptured appendix
  • Case scenarios

Gallbladder and Liver Surgery

  • Cholecystectomy. When can a cholangiogram be separately reported?
  • Liver biopsy: percutaneous vs open
  • Liver resections – How many hepatectomies (47120) are too many?

Breast Procedures NEW Guidelines!

  • Breast biopsy: percutaneous, incisional, and excisional
  • Sentinel node mapping and excision
  • Lymph node dissection: How does this change coding?
  • Mastectomy coding: lumpectomy, simple and radical mastectomies
  • Reporting closures and local advancement flaps
  • Can placement of a marker in a lumpectomy cavity be reported?
  • Case scenarios

2:00PM — 2:15PM


2:15PM — 4:00PM

Procedure Coding (continued)

Pancreatic Resection NEW!

  • Whipple procedures
  • Other pancreatic resections
  • Intra-abdominal vein reconstruction in abdominal procedures

Intra-abdominal Tumor Resection

  • What can be separately reported?
  • Coding HIPEC and getting paid

Endocrine Surgery

  • Thyroid
  • Parathyroid
  • Adrenal

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Coding Coaches