Bundling edits applied too broadly
Distinct procedures folded into a primary code because no one checked whether documentation supported separating them.
SURGICAL & PROCEDURAL
High-dollar claims deserve to be worked one at a time
Surgical revenue is not lost in volume — it is lost on a modifier, a global period, or an authorization that no longer matches what was performed. MBS bills operative work through a defined sequence, with the operative note read at every step.
Global periods
Tracked per procedure so post-op visits are not billed twice or written off
Modifier discipline
22, 50, 51, 59, 78, 79 and the payer edits that override them
Implants & devices
Invoice-backed billing where the contract requires it
ASC + professional
Facility and surgeon claims reconciled against the same operative note
HOW A SURGICAL CLAIM MOVES
Five steps, in this order, on every case
Nothing here is optional or applied only when a claim looks difficult. The sequence is the control — it is what keeps a $9,000 claim from being handled like a $90 one.
01
Authorization before the date is confirmed
Most surgical write-offs are decided before the patient is in the room. We verify benefits, confirm the authorization covers the exact planned CPT range, and flag when the surgical plan has drifted from what was approved.
In practice
- Planned procedure codes matched to the approved codes
- Assistant surgeon and co-surgeon coverage confirmed in advance
- Site-of-service restrictions checked against the scheduled facility
02
Operative note read, not skimmed
Certified coders read the full operative report — approach, findings, laterality, separate lesions, and anything performed beyond the scheduled procedure. Coding from the header line is where surgical revenue disappears.
In practice
- Laterality and multiple-lesion documentation confirmed
- Unplanned or extended work captured with supporting language
- Queries sent to the surgeon rather than assumptions made
03
Bundling and multi-procedure review
Before submission, each claim runs against payer-specific edits: NCCI pairs, multiple-procedure reductions, bilateral rules, and the modifiers that legitimately unbundle a distinct service.
In practice
- Sequenced by RVU so reductions apply to the right lines
- Modifier 59 / X-modifiers used only where documentation supports it
- Payer edit differences maintained per contract, not applied generically
04
Submission, then same-week follow-up
Surgical claims are high-dollar, so they are worked individually. Rejections are corrected the same day; unpaid high-value claims get direct payer follow-up rather than sitting in an aging report.
In practice
- High-dollar claims prioritized by value and payer behavior
- Clearinghouse rejections corrected before they age a day
- Written status notes attached to each claim touch
05
Appeals with the operative note attached
Denials for medical necessity, bundling, or assistant-surgeon coverage are appealed with the specific documentation the payer's own policy calls for — and the pattern is fed back so the next case is coded to avoid it.
In practice
- Payer policy language quoted in the appeal
- Reason codes grouped monthly to expose repeat causes
- Preventable causes routed back to scheduling or coding
What the engagement covers
- Professional (surgeon) and facility / ASC billing
- Certified surgical coding with operative-note review
- Prior authorization and benefit verification
- Implant and device billing with invoice support
- Global-period tracking and post-op visit handling
- Bundling, modifier, and multi-procedure edit review
- Denial appeals and underpayment recovery
- Contract-rate comparison on paid claims
- Monthly reporting by surgeon, procedure, and payer
Four leaks we look for first
In surgical practices these four account for most of the recoverable revenue we find during a first review.
Global-period confusion
Post-operative visits either billed inside the global period or written off when they were genuinely unrelated.
Authorization drift
The approved procedure and the performed procedure no longer match, and the denial arrives after the case is closed.
Under-collected contract rates
Multi-procedure reductions applied more aggressively than the contract allows, paid quietly and never appealed.
Questions surgical practices ask
Do you bill both the surgeon and the facility?
Yes. We handle professional claims for surgeons and facility claims for ambulatory surgery centers, reconciled against the same operative note so the two sides do not tell the payer different stories.
Are your coders certified for surgical specialties?
Surgical work is assigned to certified coders with operative-note experience in that specialty. Coding questions go back to the surgeon as a written query — we do not guess at intent.
How do you handle implant and device costs?
Where the contract allows separate reimbursement, we bill with invoice support attached and track whether the payer honored the carve-out. Where it does not, we say so rather than submit and hope.
Can you take over an existing aged surgical A/R?
Yes, and it is often the first engagement. High-dollar surgical claims are the best candidates for recovery work because the effort per claim is justified by the balance.
Which systems do you work in?
We work inside your practice management and EHR system rather than moving you onto ours. Integration is confirmed during onboarding before any go-live date is set.
Where surgical work usually connects
Medical Coding
Certified coding and audit support for operative reports and procedural documentation.
Denial Management & Appeals
Bundling, medical-necessity, and assistant-surgeon denials worked to root cause.
Credentialing & Enrollment
Surgeon enrollment and facility privileging kept current so cases can be billed.
Looking for another specialty? See all specialties.
Send us your ten largest open claims
We will tell you which are recoverable, what is blocking each one, and whether the issue is coding, authorization, or contract application. The findings are yours either way.
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