Surgical Billing Guide: 2026 General Surgery Codes, Global Package and NCCI Rules

• Surgical laparoscopy and endoscopy include the diagnostic look, and a conversion to open is billed as the open procedure only (NCCI ch. VI §C.1, §C.13, §F.1, §F.4).
• Hernia repairs at the incision site, incidental appendectomies and routine lysis of adhesions are included in the main procedure (§E.3–4, §E.9, §F.5–6).
• Anterior abdominal hernias are one code per session, chosen by total defect size, with mesh included (ACS; §E.7).
• Closure, urinary catheters, bleeding control and postoperative pain management by the surgeon are part of the package (§H.19–22).
• 58, 78 and 79 are three different statements, and only 78 does not start a new global period (MLN907166).

The American College of Surgeons publishes coding guidance for its members in its Coding and Billing resources (read November 9, 2026).

CMS’s Global Surgery booklet (MLN907166) defines three packages. A 000-day procedure (endoscopies and some minor procedures) has no pre- or postoperative days. A 010-day procedure runs 11 days: the procedure day and the ten after. A 090-day major procedure runs 92 days: the day before, the procedure day and the ninety after. The package applies in every setting, including the ICU.

An “operating room” for modifier 78 is a place equipped and staffed for procedures, including an endoscopy suite and a cardiac catheterization suite, but not a patient room, minor treatment room, recovery room or ICU unless the patient was too unstable to move (MLN907166).

Florida groups report 99024

NCCI chapter VI §F and chapter I §E.c set the rules. They apply whether or not a specific edit exists for the code pair: CMS says a coder may not choose a laparoscopic and open combination just because it is not in the NCCI tables.

• Exploration is included. Exploratory laparotomy 49000 is not reported with an open abdominal procedure (§E.1).
• Gallbladder removal is included in hepatectomy (47120–47130, 47133–47142) and Whipple-type pancreatectomy (48150–48154); 47562–47564 and 47600–47620 are not added (§E.2, §E.11).
• Extensive enterolysis is modifier 22, not a code. Open (44005) and laparoscopic (44180) enterolysis are “separate procedures.” When enterolysis is extensive and time-consuming, append 22 to the main procedure; the MAC decides whether to pay more (§E.9).
• Iatrogenic injury repair is included. Suture of small or large intestine (44602–44605) is not billed for a laceration made during an enterectomy, colectomy, gastrectomy or similar procedure (§E.10).
• Approach families are mutually exclusive. Colectomy (44140–44160), gastrectomy (43620–43635), pancreatectomy (48140–48155) and proctectomy (45110–45123) codes describe different approaches to the same result; report one (§H.11).
• Panniculectomy at the incision is included; 15830 is not reported for it, although a true abdominoplasty may be (§E.8).

Since January 1, 2023, anterior abdominal hernias are reported with one family of codes for any approach, open or laparoscopic; the old open codes 49560–49590 and laparoscopic codes 49652–49657 were deleted. The structure, as the ACS Bulletin described it before the change took effect:

• One code for all the hernias. The repair code is reported once, on the total defect size of every anterior abdominal hernia repaired in the session; if any is incarcerated or strangulated, the session is coded that way.
• Measure before opening the defect, because the fascia retracts, and record the measurement in the operative note.
• Mesh is included. NCCI §E.7: mesh implantation codes (15777, 57267, 0437T) are not reported with a procedure that includes a hernia repair unless CPT specifically allows it.
• Incision-site and incidental hernias are not separate (§E.4).
• 0-day global. ACS reports the new primary codes were valued with a 0-day global period, so later visits are billed as E/M. Check the current indicator in the PFS Look-Up Tool before you rely on it.

Inguinal, femoral and lumbar hernia repairs keep their own codes and may be reported with an anterior abdominal repair in the same session with modifier 59, per the same ACS article.

Surgeons who perform GI endoscopy follow NCCI chapter VI §C:

• Surgical endoscopy includes diagnostic endoscopy of the same area, and only the more extensive procedure is reported: a sigmoidoscopy completed before a colonoscopy at the same encounter is not billed (§C.1, §C.12).
• Most comprehensive code first, with modifier 51 on the secondary code when one code does not describe everything done (§C.2).
• The same technique several times in one region is one unit, for example several polypectomies by the same method (§C.3).
• Snare and biopsy on different lesions. The 45385/45380 edit may be bypassed with 59 or XS for separate lesions, or 59 or XE for separate encounters (§H.25).
• Bleeding control is included; a repeat endoscopy for bleeding at a separate encounter the same day takes modifier 78 (§C.11).
• Endoscopy before or during an open procedure. An endoscopy to assess landmarks is not separate; a diagnostic endoscopy that decides an open procedure may be, with 58 (§C.6, §C.14).

For a 78 return, bill the code for what was done on the return trip, not the original surgery, unless the same procedure was repeated. Control of bleeding that needs a return to the OR is reported with 78; bleeding controlled without one is in the package (NCCI §H.22).

NCCI chapter VI §H lists services that are never billed with an operation by the operating surgeon:

• Anesthesia by the surgeon (00100–01999, 62320–62327, 64400–64530) and its components such as IV start or ECG; moderate sedation 99151–99153 is generally separately reportable (§H.19).
• Postoperative pain management by the surgeon, including 36000, 36410, 62320–62327, 64400–64489 and 96360–96379 when used for it (§H.19).
• Urinary catheter insertion, 51701–51703, with any 000, 010 or 090 procedure (§H.20).
• Closure of the surgical incision with repair codes 12001–13153 (§H.21).
• A fine needle aspiration and another biopsy of the same lesion: report one (§H.24).

Each rule above becomes a denial when it is missed. The ones this guide covers: a decision-for-surgery visit without 57, a laparoscopic code billed with the open procedure it converted to, a hernia repair billed at the incision site or with a mesh code, several hernia codes where one total-defect code applies, lysis of adhesions billed as its own line instead of 22 on the main procedure, an incidental appendectomy, and a return to the OR billed with 79 or 58 when 78 was the correct statement. How a denied claim gets worked once it comes back is covered on our denial management page.

• Medicare NCCI Policy Manual 2026, Chapter VI: Surgery, Digestive System (revision date January 1, 2026; read November 9, 2026)
• Medicare NCCI Policy Manual 2026, Chapter I: General Correct Coding Policies, §E Modifiers (read November 9, 2026)
• CMS MLN907166, Global Surgery (December 2025)
• Medicare Claims Processing Manual, Chapter 12, §40.4, §40.6, §40.7 (Rev. 13753, issued May 7, 2026)
• ACS Bulletin: Coming in 2023, Extensive Changes for Reporting Anterior Abdominal Hernia Repair (November–December 2022; read November 9, 2026)
• CMS fact sheet: CY 2026 Medicare Physician Fee Schedule final rule (CMS-1832-F) (October 31, 2025)
• CMS, Global Surgery Data Collection (read November 9, 2026)
• American College of Surgeons, Coding and Billing (read November 9, 2026)

CPT codes and descriptors are from the AMA CPT code set. This guide does not state fee amounts; check your Medicare contractor’s fee schedule and your payer contracts.

What is included in the global surgical package?

Preoperative visits after the decision to operate (the day before a major procedure), the operation, postoperative visits for recovery, postoperative pain management by the surgeon, complications that do not need a return to the OR, and routine care such as dressing changes and removal of sutures, staples, drains and catheters. CMS lists them in its Global Surgery booklet, MLN907166.

Can a diagnostic laparoscopy be billed with a surgical laparoscopy?

No. Surgical laparoscopy includes diagnostic laparoscopy in the same body cavity at the same encounter. A diagnostic laparoscopy is separately reportable only when its findings lead to a decision to do an open procedure, usually with modifier 58.

How do I bill a laparoscopic procedure converted to open?

Report only the open procedure. NCCI says neither the surgical nor the diagnostic laparoscopy code is reported when a laparoscopic procedure is converted to an open one, whether or not a specific edit exists for that code pair.

How are anterior abdominal hernia repairs coded since 2023?

With one code from 49591–49596 for an initial repair or 49613–49618 for a recurrent repair, chosen by total defect size (under 3 cm, 3 to 10 cm, over 10 cm) and by whether any hernia is incarcerated or strangulated. Mesh is included, and the code is reported once for all anterior abdominal hernias repaired in the session.

Can I bill a hernia repair found during another abdominal operation?

Not if it is at the incision site for the open or laparoscopic procedure, and not if it is incidental. NCCI chapter VI says a hernia repair is separately reportable only at a site other than the incision and when medically necessary.

Is an appendectomy billable with another abdominal procedure?

Only when the appendix is diseased and its removal is medically necessary. Removal of a normal appendix during another open or laparoscopic procedure is incidental and not separately reportable.

How does Medicare pay co-surgeons and assistants?

Each co-surgeon bills the procedure with modifier 62 and is paid 62.5% of the global amount. Team surgery with modifier 66 is paid by report. An assistant at surgery is paid 16% of the surgical amount, using 80, 81, 82 or AS for PAs, NPs and CNSs, and only for procedures where assistants are allowed.

What is the difference between modifiers 58, 78 and 79?

Modifier 58 is a staged or planned procedure, a more extensive one or therapy after a diagnostic procedure; a new global period starts. Modifier 78 is an unplanned return to the OR for a related procedure; it is paid at the intra-operative portion and no new period starts. Modifier 79 is an unrelated procedure; a new period starts.

What changed for general surgery billing in 2026?

The 2026 NCCI Policy Manual took effect January 1, 2026. The CY 2026 fee schedule set conversion factors of $33.57 and $33.40 and applied a -2.5% efficiency adjustment to non-time-based services, which includes surgical codes. CMS also asked for comment on 90-day global payment accuracy without finalizing a change.