Well, when you talk about general surgery, it doesn’t seem very difficult but, when it comes to CPT coding for general surgery, it’s quite worrisome! How do you code general surgery? General surgery is considered one of the most important sub-divisions of the healthcare industry. It’s even more crucial for surgeons and hospitals to concentrate more on developing general surgery departments at better levels. Several patients are in need of general surgeries during emergencies and even during other times.

CPT coding for general surgery is at times difficult as it involves different procedures and one should keenly concentrate on what they are billing and coding for! Two years back, general surgeons were dealing with 135 ICD-10 code changes and more than 69 CPT updates. It’s indeed a large number to remember. Outsourcing medical billing and coding can save surgeons from loss and help them escape the apocalypse.

Just like general surgery, there are several areas and sections where CPT coding plays a prominent role in revenue generation. Just take a look at them!

CPT Coding updates for Surgery Section:

  • Integumentary System-Breast Repair and Reconstruction. For 2021, there were 15 codes updated and two codes deleted (19324 and 19366) in the breast repair and reconstruction subsection (19316-19499) of the Integumentary System section.
  • Coders additionally will find new instructional guidance for each CPT code and new fundamental guidelines in this subsection. The new guidelines provide specified information on the types of reconstruction used to improve checks using several techniques, including latissimus dorsi flap; free flap; GAP flap, and single or pedicled transverse rectus abdominis myocutaneous (TRAM) flap.
  • CPT coding guidelines especially explain whether different reconstruction methods are performed on each breast. The coding part has been updated and the title ‘mammary’ was substituted with the term ‘breast’ and now incorporates language to indicate if the breast implant insertion was performed on the same day or at a particular time as a significant mastectomy.

Respiratory System – Nose:

  • Code 30468 is unique and was created to explain the repair of a nasal valve collapse with subcutaneous or submucosal lateral wall implants. It also required a code to recognize opening the nasal collapse via minimally invasive methods and using absorbable lateral wall implants. Parenthetical direction for code 30468 notes that this code is to be used to report a bilateral system. If the process is performed unilaterally, add modifier 52.

Respiratory System – Lungs and Pleura: 

  • Code 32408 is designed for 2021 to report core needle biopsy of the lung or mediastinum using all imaging guidance types, including, but not restricted to, CT, MRI, ultrasound, and fluoroscopy.
  • The current guidelines for 32408, state that imaging guidance is not to be listed separately, and the code is only used once per lesion tested in a single session. If multiple lesions are tested on a corresponding day, select 32408 for each lesion examined simultaneously, including modifier 59.

Male Genital System – Prostate: 

  • Code 55880 is added to report transrectal, high-intensity-focused ultrasound (HIFU) guided ablation of malignant prostate tissue. Before 2021, coders were following an unrecorded code to communicate that method.

Female Genital System – Cervix Uteri:

  • Code 57465 is a unique add-on code generated to report computer-aided colposcopy to assist in the cervix’s biopsy. Code 57465 is used in combination with vaginal colposcopy procedures (57420, 57421) and cervical colposcopy procedures (57452-57461). The 57465 specification states that it combines optical dynamic spectral imaging that aids in the mapping of abnormal measures for biopsy.

Auditory System – Other Procedures:

  • New codes are designed for dilation of the eustachian tube practicing the nasopharyngoscopy technique. This procedure is generally referred to as eustachian tube balloon dilation (ETBD). Before 2021, coders used unlisted code 69799 to report this procedure because no specific code was available. The information shows that 69705 is for unilateral dilation and 69706 is for bilateral dilation.


What does General Surgery cover?

Removing lumps:

  • A lump in the body is not a disease. Patients with lumps in their bodies might feel it quite surprising to hear about it.
  • But to help with removal general surgeons can get into the medical industry. It is very important and necessary for patients with lumps to visit a general surgeon and treat it.
  • General surgery is one of the most important areas of the healthcare industry where income generation is better. In today’s scenario, there are so many advancements being used in general surgery for dealing with multiple problems.

Some of the surgeries which come under general surgery are

  • Gastroenterology
  • Gynecology
  • Otolaryngology


CPT Coding for Radiology Section

  • Diagnostic Radiology—Chest.

Prior to 2021, there was not a code to specify a computed tomography (CT) scan for lung cancer screening. For 2021, new code 71271 was created to report a new low-dose CT scan for lung cancer screening. Codes 71250, 71260, and 71270 were revised to include the terminology “diagnostic,” since these codes are now to be used for diagnostic examination and not to screen an asymptomatic patient. The parenthetical guidance for code 71271 specifically notes this is not for breast CT procedures.

Medicine Section

Audiologic Function Test-Auditory Evoked Potentials (AEP):

  • Four new CPT codes were added to the audiologic function test family of codes (92650-92653) and two codes have been deleted (92585 and 92586). New parent code 92650 captures the work of a newborn hearing screen. There are three new child codes.
  1. Child code 92651 captures post-screening follow-up for AEP.
  2. Child code 92652 captures extensive electrophysiologic estimation of behavioral hearing thresholds.
  3. Child code 92653 was added to report neurodiagnostic assessment using AEP response to evaluate neural conduction.


Cardiovascular Monitoring Services-External Electrocardiographic (ECG) Reporting: 

  • There were a conversion of eight Category III codes (0295T-0298T) to Category I codes (93241-93248) to describe external ECG recording. Also, new guidelines and parenthetical notes have been added and existing guidelines have been revised in the cardiovascular monitoring section. New codes 93241-93244 are used to report external ECG for more than 48 hours and up to seven days. New codes 93245-93248 are used to report external ECG of more than seven days and up to 15 days.


In order to stay updated with the new upcoming CPT codes, have a trained medical coding team or outsource medical coding to better medical billing and coding companies.


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