Surgical Coding Resources
Plain-English guides to coding surgical procedures accurately — CPT codes, modifiers, work RVUs, and the documentation that supports them. Jump to your specialty below.
Coding Fundamentals
Bilateral Procedures and Modifier 50: Getting Paid Correctly
When you operate on both sides, modifier 50 captures it — but only on codes that allow it, and payers handle it inconsistently. Here's the playbook.
Read →Assistant Surgeon Modifiers (80, 82, AS): When and How to Bill
Assistant-at-surgery is legitimate reimbursement that's often left uncaptured — or billed without support. Here's how 80, 82, and AS work.
Read →The Global Surgical Period: Modifiers 24, 25, 57, 58, 78, and 79
The global package bundles routine post-op care — but legitimate separate services during that window need the right modifier or they get denied. A field guide.
Read →Modifier 59 and the X{EPSU} Modifiers: Coding Distinct Procedures Correctly
Modifier 59 unbundles procedures that are genuinely separate — but it's one of the most audited modifiers in medicine. Here's how to use it defensibly in orthopedics.
Read →Cardiothoracic Surgery
Valve and Thoracic Coding: Repair vs. Replacement, Open vs. VATS
Valve codes split by valve and by repair versus replacement; thoracic resections split by extent and approach. The other half of the cardiothoracic code set.
Read →CABG Coding: Arterial Codes, Venous Add-Ons, and the Harvest Rules
Bypass coding is a two-part system — arterial graft codes plus venous add-ons — with harvest bundled except when it isn't. How to code a multi-vessel CABG correctly.
Read →Colon & Rectal Surgery
Colonoscopy Coding: Screening vs. Diagnostic, Polypectomy, and Modifier PT
Whether a colonoscopy is screening or diagnostic changes the code and the modifiers, and polypectomy is coded by technique. The rules that drive endoscopy claims.
Read →Anorectal Coding: Hemorrhoid Columns, Fistula Depth, and the EUA Rule
Hemorrhoidectomy codes count columns, fistula codes track the muscle, and the exam under anesthesia almost never stands alone. Coding the anorectal case correctly.
Read →Dermatology
Destruction and Mohs: Coding AKs, Benign Lesions, and Micrographic Surgery
Destruction codes split premalignant, benign, and malignant with lesion counts, and Mohs is stage-based by anatomic site. The rules for these high-volume derm services.
Read →Skin Biopsies and Lesion Removal: Biopsy vs. Shave vs. Excision
Dermatology's most frequent codes hinge on documented intent and technique — and the biopsy codes now follow a strict hierarchy with add-ons.
Read →General Surgery
Hernia Repair Coding After the Overhaul: Defect Size, Mesh, and Recurrence
The anterior abdominal hernia codes were rebuilt around defect size and clinical state, with mesh now bundled. Here's how to code inguinal and ventral repairs correctly.
Read →Coding Laparoscopic Cholecystectomy: 47562, 47563, and What's Bundled
The lap chole family is a lesson in comprehensive codes: cholangiography, adhesiolysis, and conversion to open each have specific rules. Here's how to get it right.
Read →Neurosurgery
Cervical Spine Coding: ACDF, Corpectomy, and Anterior Instrumentation
Anterior cervical fusion is a stack of per-interspace codes plus separately reportable instrumentation and cages. How to build the ACDF claim level by level.
Read →Coding Lumbar Decompression and Fusion: Levels, Add-Ons, and Instrumentation
Spine coding is per-level, add-on-driven, and unforgiving of vague notes. How decompression, interbody fusion, and instrumentation fit together on a claim.
Read →Obstetrics & Gynecology
Obstetric Delivery Coding: Global Packages, Cesarean, and VBAC
OB care is billed as a global package — unbundling it into visits is one of the costliest coding errors. How the delivery codes and their components fit together.
Read →Hysterectomy Coding: Approach, Uterus Weight, and Adnexa — the Three Axes
Every hysterectomy code is the intersection of three questions. Answer all three from the op note and the code picks itself — miss one and the claim is wrong.
Read →Ophthalmology
Retina Coding: Intravitreal Injections, Vitrectomy, and Detachment Repair
Injections are coded per eye with the drug billed separately, and vitrectomy codes are comprehensive. How to code the posterior-segment case.
Read →Cataract Coding: 66984 vs. 66982 — and What 'Complex' Actually Requires
The complex-cataract code pays more, and auditors know it. What documentation genuinely supports 66982, plus the combination rules for glaucoma procedures.
Read →Oral & Maxillofacial Surgery
Orthognathic and TMJ Surgery Coding: Osteotomies and Joint Procedures
Le Fort osteotomies, sagittal split, and TMJ procedures are medical CPT codes payable on functional criteria. A field guide to the OMFS reconstructive claim.
Read →Facial Fracture Coding: Open vs. Closed, Fixation, and the CPT/CDT Line
Mandible and midface fracture codes select by treatment type and fixation — and some OMFS work belongs on a dental claim entirely. A field guide for facial trauma coding.
Read →Orthopedic Surgery
Fracture Care Coding: Open vs. Closed, With vs. Without Manipulation
Fracture coding hinges on distinctions that are easy to blur in a note. Here's how treatment type and manipulation drive the code — and the RVUs.
Read →Coding Knee Arthroscopy: Meniscectomy, Chondroplasty, and What Bundles
Knee scope coding trips up even experienced surgeons. Here's how meniscectomy, chondroplasty, and loose-body removal interact — and what's separately billable.
Read →ICD-10 Specificity in Orthopedics: Laterality, Encounter, and 7th Characters
Unspecified diagnosis codes are a top denial driver. Orthopedics demands laterality and, for injuries, a 7th character — here's how to get them right.
Read →Modifier 22 in Orthopedic Surgery: When It Applies and How to Document It
Modifier 22 signals substantially greater work than usual — but it has no fixed RVU and lives or dies on documentation. Here's when it's appropriate and exactly what to write.
Read →Coding Rotator Cuff Repair: CPT Codes, Modifiers, and Common Pitfalls
Arthroscopic vs. open, what bundles into the repair, and where surgeons most often leave legitimate codes off the claim.
Read →Work RVUs Explained: How Orthopedic Procedures Are Valued
What a work RVU actually is, where the numbers come from, and why two reasonable codings of the same case can pay very differently.
Read →Otolaryngology (ENT)
Tonsils, Adenoids, and Ear Tubes: Age-Based ENT Coding
The most common pediatric ENT procedures are coded by patient age and by which structures were removed — and the anesthesia setting matters for tympanostomy.
Read →Coding Endoscopic Sinus Surgery: Per Sinus, Per Side
FESS is coded sinus by sinus and side by side — which makes it uniquely easy to undercode or overcode. A practical map of the endoscopic sinus code family.
Read →Pediatric Surgery
Pediatric Appendectomy and Pyloromyotomy: Approach, Rupture, and Modifier 63
Two of the most common pediatric-surgery operations, with rules for open vs. laparoscopic, complicated appendicitis, and the small-infant modifier.
Read →Pediatric Hernia Coding: Age Bands, Clinical State, and Modifier 63
Pediatric inguinal hernia codes are selected by the patient's age first — and the infant modifier has a rule that trips up even experienced coders.
Read →Plastic & Reconstructive Surgery
Breast Reconstruction Coding: Stages, Flaps, and Symmetry Procedures
Reconstruction codes select by technique and stage, and federal law makes contralateral symmetry procedures billable. Coding the reconstructive breast case.
Read →Lesion Excision, Repair, and Tissue Transfer: What Includes What
Plastic surgery coding is a hierarchy of inclusion: simple repair lives inside excision, excision lives inside tissue transfer. Getting the layers right is the whole game.
Read →Urology
Coding Prostate Procedures: TURP, Laser Enucleation, Rezūm, and UroLift
The BPH treatment families are mutually exclusive, and each has its own code and documentation needs. A map of transurethral prostate coding, plus biopsy.
Read →Urology Endoscopy Coding: Why Cystoscopy Disappears and When a Stent Counts
Diagnostic cystourethroscopy bundles into almost everything, and ureteroscopy codes include the stent on the treated side. The rules that drive correct urology claims.
Read →Vascular Surgery
EVAR and Open AAA Repair: Coding the Aortic Aneurysm Case
The endovascular aneurysm repair codes bundle catheterization, the device, and imaging into a single comprehensive code. How to code EVAR and open AAA correctly.
Read →Endovascular Coding: Why Lower-Extremity Revascularization Is One Code, Not Five
Modern vascular code families bundle access, catheterization, angiography, and the intervention into a single comprehensive code per territory. The logic, explained.
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