Best Practices in Surgery Coding​

Maintaining positive cash flows and a robust hospital revenue cycle are essential for maintaining smooth operations in hospitals, especially surgical centers. Accurate surgery coding and billing are at the core of hospital revenue cycle management. Even minor errors in surgery coding have magnified impact on the revenue cycle and cash flow as they lead to billing mistakes, delays in processing bills, claim denials and reduced reimbursements. 

Challenges in surgery coding

  • Unclear reporting and under-reporting, especially when multiple procedures are done in a single surgery, by surgeons lead to under-coding and inaccurate coding as coders may not necessarily know that extra steps or procedures were included unless detailed in reports. This causes a loss in revenue. 
  • Coding is done on the basis of the headings or schedules rather than the content of the detailed surgery reports causing discrepancies and errors in coding and billing. 
  • Missed and misused modifiers resulting from unclear reporting by the surgeon or oversight by coders. These often lead to fraud accusations and claim denials. 
  • Staff who are responsible for surgery coding do not have the necessary expertise or they are overburdened with other tasks and functions causing oversights and inaccurate coding. 
  • Repeat coding errors as a result of the staff/ coders not tracking denials to identify the weaknesses 
  • Broken/ ineffective communication between coders and surgeons leading to information silos and inaccurate coding. 

Best Practices in surgery coding

Here are the best practices you should follow in surgery coding to ensure accuracy, enhanced reimbursed and positive cash flows. 

1. Always code for the detailed physician report on the surgery 

The actual procedures may be different than what was scheduled due to a need that emerged during surgery. The headings on operative reports do not capture the details and nuances in the description. So, it is crucial to code for the detailed surgery report by the physician/ surgeon rather than the schedule or the headings on operative reports. It is important that coding and billing happen after the surgery is completed and the surgeon has given the detailed operative report (written, oral or dictated). 

2. Educate surgeons on the importance of detailed and accurate surgical reporting 

The coders may not be present during the surgery and so depend solely on the surgery reports from surgeons to code and bill thereafter. When the operative reports and notes do not accurately capture the pertinent details of the diagnosis, procedure, counselling, prescription, steps during the surgery, etc., they cannot be coded accurately. This often leads to under-coding, missed or misused modifiers and revenue losses. For instance, if multiple techniques or steps were used during a single surgery to remove a cyst, then the operative report/ notes/ dictation must reflect the same so that the coders can code accordingly. It is important to educate surgeons about the importance of detailed, clear and methodical reporting of the surgery. 

3. Avoid over-coding/ upcoding 

It is essential to code and bill only for procedures that have been performed, medicines that were used and prescribed during the procedure, actual equipment and staff time and not more. Over-coding/ upcoding, inflating time and costs, etc. will lead to legal trouble, even if it was unintentionally done. 

4. Employ coding staff who have expertise in surgery coding 

Surgeons and hospital staff may believe that they are best suited to code surgeries because they are experts in surgery. However, surgery coding is dynamic, and it is essential for surgery coders to keep themselves abreast of the changes in regulations, requirements, etc. Considering the tight schedules of surgeons, they may not have the time and/or willingness to do so and this will lead to under-coding and inaccurate coding and therefore, revenue losses. Surgeons specialize in certain areas as one doctor cannot have expertise in all the fields. Similarly, coding must be done by specialized coders with the necessary skills, experience and expertise. 

5. Ensure effective communication and transparency between surgeons and coders

To avoid inaccurate coding and to ensure that all the nuances of the surgery are properly captured in coding, there needs to be open and effective communication and transparency between surgeons and coders.  

6. Hire services of expert coding specialists and/or consultants  

Hiring the services of expert revenue cycle management companies like Atom Healthcare USA will enable hospitals and surgical specialty centers to focus on providing high-quality patient care while coding and billing are fully taken care of. 

Atom USA has a team of AHIMA-certified and AAPC-certified medical coders, experts in medical coding services and experienced healthcare practitioners who offer customized surgery coding solutions to help you improve your revenue cycle yield through high-quality, accurate coding. 


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