Global-period tracking, bundling-aware coding, prior authorization for elective cases, patient marketing and a claims portal for general surgery practices, built on CMS rules and your payers' own policies.
Quick answer
General surgery billing services code, submit and follow up claims for office procedures, outpatient cases and major operations. The work centers on 0-, 10- and 90-day global periods, modifiers such as 57, 58, 78 and 79, NCCI bundling edits and prior authorization for elective cases. RCM Finder adds front-desk assistants, patient marketing and a claims portal.
General surgery billing is different because one practice bills office procedures, outpatient cases and major operations, each with its own global period, site rate and bundling rules. Most lost revenue starts with a modifier or bundling decision, not a typo.
CMS's Global Surgery Booklet (December 2025) sets three windows: 0 days for endoscopies and some minor procedures, 10 days after other minor procedures, and 90 days after major operations, plus the day before. The package applies in every setting, and same-specialty surgeons in one group bill as one physician.
The CY 2026 Physician Fee Schedule final rule fact sheet (October 31, 2025) set a $33.40 conversion factor for clinicians who are not qualifying APM participants and a -2.5% efficiency adjustment to work RVUs of services that are not time-based. E/M visits are exempt.
For 2027, CMS's proposed rule (July 14, 2026) would pay the most expensive service at 100% and others at 50% when one practice bills an office or outpatient E/M visit on the same day as a 0-, 10- or 90-day global procedure. It also says post-op visits in global periods are not occurring. Check the final rule.
We build our billing pipeline around how claims actually move through a practice: registration, charge entry, submission, payment and follow-up. For general surgery, we add the global-period, bundling and site-of-service checks on this page.
Each pillar closes one handoff where surgical revenue leaks: referrals, elective case clearance, coding against bundling rules and claim visibility. We run all four against one set of payer rules.
Our healthcare digital marketing builds demand from referring offices and local patients searching for hernia, gallbladder or skin lesion care, through local SEO, Google Ads and reputation work. Tracking follows HHS guidance on online tracking.
Our virtual medical assistants for surgical practices run your front desk on your practice's time zone. They verify eligibility, start elective prior authorizations, collect the records plans ask for and book post-op visits.
Our end-to-end general surgery revenue cycle management covers coding support, claim scrubbing, denial management and A/R follow-up, with checks for open global periods, post-op modifiers, NCCI pairs and fee schedule indicators.
Our practice management system tracks every claim by stage, applies specialty-aware billing logic per claim, checks data completeness before submission and flags payments below the expected amount.
Find where your surgical claims leak
We review recent surgical claims, denials and your authorization log, then show what to fix first. Pricing is quoted after the audit.
Routine care from the decision to operate through the end of the global window is paid once, inside the surgical fee. Anything billed separately in that window needs a modifier the note supports.
Per the Global Surgery Booklet, the fee covers pre-op visits after the decision to operate, the operation, complications treated without a return to the OR, follow-up visits and routine wound care. Diagnostic tests, unrelated visits, new distinct procedures and returns to the OR are separate.
Since 2025, modifier 54 applies to every 90-day package where the surgeon expects to provide only the surgery, even informally, per the CY 2025 final rule fact sheet. Whoever bills 55 must provide a post-op service first, and add-on G0559 pays for post-op visits by a practitioner who did not operate. See our guides to modifier 79 and co-managed post-op care.
Most general surgery denials come from bundling: billing what the main procedure already includes, coding two approaches to one operation, or using a modifier to pass an edit.
Codes are examples in our own words (the AMA owns CPT descriptors), with rules from the 2026 NCCI Policy Manual chapters on general policy, the integumentary system and the digestive system.
| Procedure family | Code examples (our wording) | Rule to know | Where claims break |
|---|---|---|---|
| Inguinal hernia | 49505 (open, first repair, age 5+, reducible); 49650 (laparoscopic, first repair) | Bilateral: 50 on one line, one unit, if allowed. No mesh code unless CPT allows it. | Two lines without 50; a mesh code added |
| Ventral and incisional hernia | 49591 to 49596 (first repair, by defect size and whether incarcerated); 49613 (recurrent, under 3 cm) | A repair at another operation's incision, or an incidental repair, is not billed. | Total defect size missing from the note |
| Gallbladder | 47562 (laparoscopic); 47563 (with cholangiography) | Diagnostic laparoscopy and incision closure are included. After conversion, bill only the open procedure. | Diagnostic laparoscopy added; both approaches billed |
| Appendix | 44970 (laparoscopic); 44950 (open) | Removing a normal appendix during another abdominal operation is not billed. | Incidental appendectomy added to another case |
| Colon resection | 44140 (open partial colectomy); 44204 (laparoscopic) | Adhesion lysis is included (extensive lysis may support 22), as is endoscopy within an open colectomy. | 44005 or 44180 billed with the resection |
| Breast | 19301 (partial mastectomy); 19303 (simple mastectomy); 38525 (deep axillary node removal) | A biopsy that decided the surgery takes 58 on the excision. Codes are generally unilateral. | Biopsy billed when the diagnosis was already known |
| Skin lesions and repairs | 11402 (benign, trunk or limbs, 1.1 to 2.0 cm with margins); 11602 (malignant, same size); 12032 (intermediate repair); 13101 (complex repair) | Simple closure is included; intermediate or complex repair may be billed unless it closes a benign excision of 0.5 cm or less. | Simple repair billed with the excision |
| Abscess and wound infection | 10060 (simple drainage); 10061 (complicated or multiple); 10180 (postoperative wound infection) | Not billed within another procedure at that site; 10180 never at the encounter that caused the infection. | E/M with 25 for the visit that led to the drainage |
Sources: CMS NCCI Policy Manual for Medicare Services, Chapters 1, 3 and 6 (effective January 1, 2026); Noridian modifier 50 page (2026); AAPC code summaries (plain-language meanings only). Rules vary by MAC and payer; check the current CPT code set.
Per First Coast, a Medicare contractor, multiple procedure indicator 2 ranks same-day procedures by fee schedule amount: 100% for the first, 50% for the next four. Bilateral indicator 1 pays up to 150% of one side. Noridian wants bilateral procedures on one line with one unit, and Medicare's system adds modifier 51 itself.
Co-surgery needs indicator 1 (with documentation) or 2. Noridian pays co-surgeons of different specialties 62.5% each with modifier 62, and assistants 16% with 80, 81 or 82; a PA, NP or clinical nurse specialist billing AS gets 85% of that. Assistant indicator 1 means no payment, and the claims processing manual bars payment where physicians assist in under 5% of cases nationally.
Under procedure-to-procedure edits, the column two code is denied unless a proper modifier applies. CMS's April 2026 MLN booklet defines XE, XS, XP and XU (separate encounter, structure or practitioner, or an unusual non-overlapping service) and reserves 59 for when none fits. Different diagnoses alone justify none of them. See modifiers 25 vs 59 and when modifier 59 applies.
CPT sorts repairs into simple, intermediate and complex, and under NCCI chapter 3 a global procedure's own incision is not billed as a repair. ACEP's wound repair FAQ (February 2026), from the emergency physicians' society, adds two conventions: sum the lengths of repairs with the same complexity and anatomic group, and list the most complex repair first. Confirm both in the current CPT code book before billing.
For diagnoses, see ICD-10 codes for abdominal surgery. Surgeons who scope will find colonoscopy rules on our gastroenterology billing services page.
The place of service code decides whether Medicare pays the surgeon the non-facility or the facility rate, so a wrong code changes payment even when the procedure code is right.
Under section 20.4.2 of the Medicare Claims Processing Manual, Chapter 12, the office (POS 11) gets the non-facility rate. Inpatient hospital (21), outpatient hospital (22 and 19), emergency room (23) and ASC (24) get the facility rate, as does any registered hospital patient, wherever seen.
The CY 2026 OPPS and ASC final rule fact sheet (November 21, 2025) began a three-year phase-out of the inpatient-only list and added 289 procedures, plus 271 former inpatient-only codes, to the ASC covered list. We confirm the site at booking, because it also decides who needs prior authorization. See ASC vs HOPD billing for the facility side.
Start prior authorization when the case is booked, and hold the OR date until the approval is on file. Whether a case needs one depends on the plan, procedure and site.
In hospital outpatient departments, Original Medicare has required prior authorization for panniculectomy and vein ablation since July 1, 2020; standard decisions now take up to 7 calendar days, per the CMS OPD program page. The CMS OPD FAQ (2024) says a hospital claim denied for no affirmation also denies related physician and anesthesia services. Physicians may submit for the hospital.
CMS's ASC prior authorization demonstration covers five services, including panniculectomy and vein ablation, in ASCs in 10 states from early 2026; without a request, claims face prepayment review. The WISeR model (six states, 2026 to 2031) includes skin and tissue substitutes.
For bariatric surgery, Medicare's NCD 100.1 covers named procedures when the patient has a BMI of 35 or more, an obesity-related comorbidity (type 2 diabetes counts) and prior unsuccessful medical treatment. Aetna's obesity surgery policy (reviewed July 2026), for example, also asks for a program of 12 or more sessions on separate dates, with the last session within two years before surgery, and a behavioral health assessment.
Since January 1, 2026, the CMS-0057-F rule has required Medicare Advantage, Medicaid and CHIP plans to decide expedited requests in 72 hours and standard ones in seven calendar days. In the AMA's 2025 survey (released May 2026), physicians averaged 40 prior authorizations and 13 hours of staff and physician time a week.
| Payer rule | Source | What the VMA checks |
|---|---|---|
| OPD panniculectomy (15830, 15847, 15877) and vein ablation need Medicare prior authorization; no affirmation denies the surgeon's claim too | CMS OPD page, code list and FAQ (2024) | Site; one request per vein ablation; tracking number within its 120-day window |
| ASC demonstration in 10 states: voluntary request or prepayment review | CMS ASC demonstration page (2026) | The ASC's state and its chosen path |
| WISeR states: skin and tissue substitutes reviewed | CMS WISeR page (2026) | Patient's state and the planned service |
| Bariatric: BMI 35+, comorbidity, prior unsuccessful treatment | NCD 100.1 | All three documented in the chart |
| Commercial example: 12+ program sessions, the last within 2 years of surgery; behavioral health assessment | Aetna CPB 0157 (2026) | Program records and assessment before the request |
| MA, Medicaid and CHIP: 72-hour or 7-day decisions with a specific reason | CMS-0057-F (from Jan 1, 2026) | Due date logged; denial reason saved for appeal |
Sources: CMS OPD prior authorization page (modified 2026), OPD code list and FAQ (2024); CMS ASC prior authorization demonstration page (2026); CMS WISeR page (2026); NCD 100.1 (version effective 2013); Aetna CPB 0157 (2026); CMS-0057-F fact sheet (2024). Always check the member's current plan.
See our prior authorization guide for providers for the general workflow.
See what delays and denials cost you
Enter your claim volume and denial rate to estimate what denials and slow payment cost you.
Stay in-house if you have experienced surgical coders and time for authorizations. Use a billing-only vendor if claims are the only gap. Choose a four-pillar partner when problems start before the OR date.
| Job | In-house team | Billing-only vendor | Four-pillar partner (RCM Finder) |
|---|---|---|---|
| Tracking open global periods | Coder memory or EHR flags | Checked when a denial arrives | Window logged per patient; modifiers checked before submission |
| Elective case prior authorization | Surgery scheduler, between calls | Usually left to the practice | VMA tracks each request to the OR date |
| Multi-surgeon and bilateral claims | Depends on one experienced biller | Handled on the claim | Indicators checked at booking; payments compared with expected |
| Referral growth | A separate agency, or nobody | Not included | Marketing tied to booked cases |
| Reporting | EHR reports | Claim reports only | Portal and dashboards, referral to paid claim |
| Cost structure | Salaries, benefits, turnover | Varies; ask how fees are set | Quoted after a free practice audit |
The audit will show if you need only one pillar; each can be contracted alone.
We start with a free audit and change nothing until you see the findings.
We review recent surgical claims, denials and your authorization log, and map each case type to its site.
We put a Business Associate Agreement in place before accessing patient data. Then we work inside your existing EHR (for example PrognoCIS, eClinicalWorks or athenahealth).
Your main plans' authorization lists and the fee schedule indicators for your top codes become a pre-surgery checklist and portal rules.
VMAs clear elective cases. The billing team scrubs, submits and works denials and A/R.
Each week we review denials by reason, A/R days, cases cleared before the OR date and consults by source.
Talk to us about your surgical practice
Tell us your sites, case mix and hardest payer. We will tell you honestly whether we fit.
Any vendor that handles your claims is a HIPAA business associate. Get a Business Associate Agreement before it has access, and check how it limits and logs access.
HHS guidance names billing, claims processing and practice management as business associate work; subcontractors need their own agreement. The minimum necessary standard limits use to what each task needs. The Security Rule's technical safeguards cover access control, audit controls, integrity, person or entity authentication and transmission security.
We use role-based access, audit logging and encrypted (HTTPS) connections, and we put a Business Associate Agreement in place before accessing patient data. For your own side, use our HIPAA compliance checklist for medical practices.
We would rather tell you now than after you sign. Here is where we fit and where we do not.
A good fit if you are
Probably not a fit if you are
What we would do first if we were running your practice's revenue cycle tomorrow.
We log the procedure date, global days and surgeon, then check later claims for that patient against the open window.
Planned or more extensive work is 58, an unplanned return to the OR is 78, and an unrelated procedure is 79. Surgeons should say which in the note.
Assistant and co-surgeon indicators decide whether that claim can pay. We check them at booking.
We hold the OR date until the approval is on file and matches the code, side and site.
Ventral hernia codes turn on total defect size, excisions on diameter with margins, and repairs on summed length. We give surgeons a short note template.
If CMS finalizes the same-day E/M reduction, a visit and procedure on one day would no longer both pay in full. We will model your exposure.
They cover coding support, claim scrubbing, submission, denial management and A/R follow-up for surgical procedures and visits. For general surgery, that means tracking 0-, 10- and 90-day global periods, choosing the right modifiers, applying NCCI bundling edits and handling bilateral, multiple-procedure and assistant claims. We add front-desk assistants who clear elective cases, patient marketing and a claims portal. Pricing is quoted after a free practice audit.
All three apply when the same surgeon operates again during a post-op period. Use 58 for a staged or planned procedure, a more extensive one, or therapy after a diagnostic procedure; a new global period starts. Use 78 for an unplanned return to the operating room for a related problem; Noridian pays the intraoperative portion only. Use 79 for an unrelated procedure; a new global period starts.
Sometimes. For a major (90-day) procedure, the visit where the decision to operate was made, on the day before or the day of surgery, is billed with modifier 57. For a minor procedure, the decision is included, and only a significant, separately identifiable visit is billed, with modifier 25. Being a new patient alone does not justify it. CMS has also proposed reduced payment for same-day visits and procedures from 2027.
It depends on each code's fee schedule indicators. With bilateral indicator 1, a bilateral procedure on one line with modifier 50 pays up to 150% of one side. With multiple procedure indicator 2, procedures are ranked by fee schedule amount: the first pays 100% and the next four 50% each. Noridian says Medicare's system adds modifier 51 itself. Some codes already describe both sides, so check before billing.
Panniculectomy needs prior authorization in hospital outpatient departments under CMS's OPD program, and ASCs in 10 states can request it under a voluntary demonstration. For bariatric surgery, Medicare's NCD 100.1 sets coverage criteria: a BMI of 35 or more, an obesity-related comorbidity and unsuccessful medical treatment. Medicare Advantage and commercial plans set their own prior authorization rules, so check each plan.
It can be, if the vendor is treated as a business associate. HIPAA requires a Business Associate Agreement before the vendor receives patient data, and the agreement must require the vendor to safeguard it. The Security Rule's technical safeguards include access control and audit controls. We put a Business Associate Agreement in place before accessing patient data and work inside your existing EHR, for example PrognoCIS, eClinicalWorks or athenahealth.
Tell us about your practice. A member of our operations team replies within one business day.
Pricing is quoted after the audit, based on your volume and the services you choose. Prefer to talk? Call +1 (302) 556-2288.
Tell us about your practice
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