On-DemandSpecialty Courses

The General Surgery Coding Professional: A Comprehensive Training Program

In general surgery, the procedure title rarely tells the whole story. Hernia repairs, bowel resections, breast operations, and wound procedures each have details that change the coding picture, from defect size and operative approach to what was removed or repaired. We will work through those differences using general surgery operative cases. The course covers hernia repair, hepatobiliary procedures, bowel and colorectal surgery, foregut and bariatric work, anorectal surgery, breast procedures, and skin and soft tissue services. Experienced coders will practice finding the parts of a report that support a code, recognizing included surgical work, and asking better questions when documentation is unclear.

50 lessons

Webinar Objectives

Follow abdominal, gastrointestinal, breast, and soft tissue anatomy in operative reports.
Recognize the differences among open, laparoscopic, and robotic procedures.
Identify documented defect size, extent of resection, anastomosis, and repair details.
Recognize clinical details already documented without interpreting them independently.
Find the passages in operative reports that support a proposed CPT code.
Distinguish separately reportable work from services already included in another code.
Use current CPT instructions, coding guidance and applicable edits to check code selection.
Recognize missing, unclear or conflicting details that could affect coding accuracy.
Know when a physician clarification is needed and when the existing record is sufficient.
Explain coding decisions clearly to providers and clinical staff using the documented work.

Format & Logistics

Format: Self-paced, online

Curriculum: 10 modules, 16 instructional hours

Access period: 6 months from enrollment

Credential: Healthcare Inspired Certificate of Completion

Audience: Experienced medical coders, general surgery coders, coding auditors, documentation specialists and revenue integrity professionals

Recommended background: Working knowledge of CPT and ICD-10-CM coding

Completion requirements: All 10 modules viewed in full; all module practical applications completed; Module 1-9 assessments passed at 70% (125 questions total, unlimited retakes) to unlock each next module; Module 10 Final Competency Assessment (30 questions + 5 comprehensive operative report case reviews) passed at 80%

HCI documentation review method: IDENTIFY, UNDERSTAND, LOCATE, VALIDATE, CLARIFY

Regular tuition: $99. Included at no additional cost for Annual HCi members in a qualifying tier (Signature, Premier or Pinnacle) via your membership's specialty course redemptions.

Important Disclaimers

This course is for educational purposes only and does not constitute legal, compliance, or professional advice. Always consult your organization's legal counsel, compliance officer, or payer-specific guidance before applying any coding, billing, or documentation practice discussed here.

CPT® is a registered trademark of the American Medical Association (AMA). Healthcare Inspired is not affiliated with or endorsed by the AMA.

This course does not offer CEU credit on its own. HCi members have access to separate CEU-eligible live webinars and events as part of their membership, and this specialty course is included in qualifying HCi membership tiers.

Course Content

Module 1: Foundations of General Surgery Documentation Analysis

Lesson 1.1: Your Role in General Surgery Coding

Lesson 1.2: Reading the Operative Report

Lesson 1.3: Terms That Change the Code

Lesson 1.4: Approaches and Conversions

Lesson 1.5: Researching General Surgery Codes

Module 2: Hernia Repair Documentation

Lesson 2.1: Types of Hernias

Lesson 2.2: Anterior Abdominal Hernia Codes

Lesson 2.3: Measuring the Defect

Lesson 2.4: Groin Hernias

Lesson 2.5: Included and Separate Work

Module 3: Gallbladder, Biliary & Liver Documentation

Lesson 3.1: Biliary Anatomy

Lesson 3.2: Cholecystectomy Codes

Lesson 3.3: Conversions and Inclusions

Lesson 3.4: Cholangiography and Duct Exploration

Lesson 3.5: Liver Procedures

Module 4: Bowel & Colorectal Surgical Documentation

Lesson 4.1: Bowel Anatomy

Lesson 4.2: Small Bowel and Colon Resections

Lesson 4.3: Ostomies and Reversal

Lesson 4.4: Appendectomy

Lesson 4.5: Adhesiolysis and Inclusions

Module 5: Esophagus, Stomach & Bariatric Surgery Documentation

Lesson 5.1: Foregut Anatomy and the Operative Ending

Lesson 5.2: Antireflux and Paraesophageal Operations

Lesson 5.3: Gastric and Bariatric Techniques

Lesson 5.4: Feeding Access and Included Endoscopy

Lesson 5.5: Diagnosis, Policy and Review

Module 6: Anorectal Surgical Documentation

Lesson 6.1: Anorectal Anatomy and Terminology

Lesson 6.2: Hemorrhoid Technique and Extent

Lesson 6.3: Fistulas, Fissures and Sphincters

Lesson 6.4: Abscess and Pilonidal Procedures

Lesson 6.5: Included Work, Diagnosis and Final Review

Module 7: Breast Surgical Documentation

Lesson 7.1: Breast Anatomy and Operative Purpose

Lesson 7.2: Biopsy and Localization

Lesson 7.3: Excision and Mastectomy Extent

Lesson 7.4: Sentinel Nodes and Mapping

Lesson 7.5: Diagnosis and Final Claim Review

Module 8: Skin, Soft Tissue, Wound & Endocrine Documentation

Lesson 8.1: Skin and Soft-Tissue Compartments

Lesson 8.2: Excision and Repair Measurements

Lesson 8.3: Tissue Transfer, Drainage and Debridement

Lesson 8.4: Endocrine Surgery

Lesson 8.5: Diagnosis, Evidence Review and Three Cases

Module 9: Documentation Support, Coding Compliance & Physician Communication

Lesson 9.1: Classify the Review Issue

Lesson 9.2: Apply the Five-Step Method

Lesson 9.3: Draft the Clarification

Lesson 9.4: Modifiers and Reporting Relationships

Lesson 9.5: Rationale, Follow-Through and the Hernia Case

Module 10: Advanced General Surgery Operative Report Analysis & Practical Application

Lesson 10.1: Plan the Review

Lesson 10.2: Measure and Select

Lesson 10.3: Test the Additional Services

Lesson 10.4: Diagnoses and Communication

Lesson 10.5: Complete the Competency Review -- Five Final Cases