Is it a daily struggle getting your physicians to precisely document their procedures? You know the drill: They code what they did, but you code what they documented. The two don't match up, which means they get paid and your facility gets denied. To stress the importance of a physician's documentation meticulously describing the procedure(s) he performed, here are a few new and revised CPT codes for 2007 that require precise documentation for you to be reimbursed.

Musculoskeletal system
With the establishment of new CPT codes for percutaneous and open distal radial fracture treatments, physicians will need to be detailed in their descriptions of these procedures. The new codes below describe varying degrees of complexity:

• 25606. Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation.
• 25607. Open treatment of distal radial extra-articular fracture or epiphyseal separation; with internal fixation.
• 25608. Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of two fragments.
• 25609. Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of three or more fragments.

For accurate code assignment, the operative report should include the following when performed:

• Was the repair intra-articular (25608) or extra-articular (25607)?
• Did two (25608) or more than three (25609) fracture fragments require internal fixation?
• When applicable, you'll need additional procedural description for open (25652) or percutaneous (25651) treatment of ulnar styloid fracture, as well as for external fixation (20690).
• Operative documentation must detail whether the fracture is found outside of the joint (extra-articular fracture) or extends into the joint (intra-articular fracture). Descriptions should include the fracture fragments involved - radial styloid fragment, volar ulnar fragment, dorsal ulnar fragment - and the fixation procedure.

With detailed operative documentation and the coder's knowledge of anatomy, code determination can be relatively straightforward.

Male genital system
CPT code verbiage for circumcision procedures has been revised to reflect the type of block and age of the patient.

• 54150. Circumcision, using clamp or other device with regional dorsal penile or ring block.
• 54160. Circumcision, surgical excision other than clamp, device or dorsal slit; neonate (28 days of age or younger).
• 54161. Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age.

For accurate code assignment, the operative report should include the:

• method of circumcision,
• age of patient and
• type of penile nerve block.

Note that CPT instructional notes listed after 54150 instruct the coder to append reduced service modifier -52 if clinical documentation for a circumcision, using clamp or other device, is performed with no mention of a regional dorsal penile or ring block.

Integumentary system
Lesion destruction codes 17000 through 17111 have also seen their share of revisions for 2007. Each code in this series has deleted the phrase "benign or premalignant." Instead, codes 17000 to 17004 are specific for the destruction of "premalignant" lesions and 17110 through 17111 are specific for the destruction of "benign lesions."

• 17000. Destruction (laser surgery, electrosurgery, cryosurgery, chemosurgery or surgical curettement, for example), premalignant lesions (actinic keratoses, for example) first lesion
• 17003. Destruction (laser surgery, electrosurgery, cryosurgery, chemosurgery or surgical curettement, for example), premalignant lesions (actinic keratoses, for example) second through 14 lesions, each. (List separately in addition to code for first lesion.)
• 17004. Destruction (laser surgery, electrosurgery, cryosurgery, chemosurgery or surgical curettement, for example), premalignant lesions (actinic keratoses, for example) 15 or more lesions.
• 17110. Destruction (laser surgery, electrosurgery, cryosurgery, chemosurgery or surgical curettement, for example), benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions.
• 17111. Destruction (laser surgery, electrosurgery, cryosurgery, chemosurgery or surgical curettement, for example), benign lesions other than skin tags or cutaneous vascular lesions; 15 or more lesions.

For accurate code assignment, the operative report should include the following:

• method (destruction versus excision),
• behavior of lesion (benign versus premalignant) and
• number of lesions.

Clinical documentation should include the method of removal (since an "excision" of a lesion is coded elsewhere in CPT) and include its own operative documentation requirements (size of lesion or margins, depth of removal).

The number of lesions destroyed will impact code selection, regardless of whether the behavior of the lesion is found to be premalignant or benign. For example, if clinical or operative documentation supports a premalignant behavior but states only "destruction multiple lesions," code determination cannot be accurately assigned without further clarification because one, two to 14 and more than 15 premalignant lesions have different code assignments.

On the other hand, if clinical or operative documentation supports a premalignant behavior and states, "destruction of three lesions," CPT coding is assigned as "17000; 17003 x 2." Add-on code 17003 is reported for each premalignant lesion on the second through 14th lesions. If clinical or operative documentation supports a benign behavior and states "destruction of three lesions," CPT code 17110 is reported once since the code verbiage states "up to 14 lesions."

"Excuse me, doctor?"
If the documentation isn't detailed to the extent that an accurate and precise CPT code can be selected, you need to query the physician for clarification. The coder isn't questioning the physician's intent, but simply ensuring the clinical documentation holds enough detail to accurately report the procedure. Remember, CPT code determination is based on documentation, not assumptions.