Gastroenterology Coding Alert

Question: Does a physician need to specifically document or use the terms “major surgery” or “minor surgery” to clearly differentiate the two classifications of surgery?

Answer: Yes. The physician or other qualified healthcare provider (QHP) should document whether a procedure is major or minor surgery. These terms are not defined by the CPT^® surgical package classification. Therefore, it’s up to the physician to clearly define it in the notes. This distinction affects not just procedure codes, but also reimbursement rate and the length of the global period. Also, incorrectly coding a surgery as major when it’s minor might increase the risk of audit and subject the provider and the practice to penalties. When in doubt, talk to your provider.