Do your op reports have gaps in the narrative that don't support the CPT code suggested by the procedure title? Such errors can delay claim submission while your coder awaits clarification from the physician. Worse, they can result in underpaid claims if the physician refuses to provide clarification or provides an inadequate response to the coder's query. Here are a dozen common documentation deficiencies.

Complex Wound Repair
Many physicians use the term "complex wound repair" in the op report procedure title, but the body of the report doesn't contain the documentation to support a complex wound repair CPT code. In a complex repair (for example, 13100 repair, complex, trunk; 1.1cm to 2.5cm), the wounds require more than layered closure, such as in a scar revision, debridement (such as traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. This type of repair may include creating the wound defect and preparing for repairs or debriding and repairing complicated lacerations or avulsions. Complex repair doesn't include excision of benign (11400 to 11446) or malignant (11600 to 11646) lesions. These guidelines apply to complex wound repair:

• The layered repair of lacerations that also require debridement of wound edges before closure.
• Wounds following excision of some lesions may require extensive undermining to release and redistribute tension vectors to allow proper closure. Wide undermining is necessary to avoid uncertain distortion such as of the eyelid or lip.
• Dog ears (Burow's triangles) may be included as part of the complex repair.

Extensive Upper Lid Blepharoplasty
Physicians sometimes use the term "extensive blepharoplasty" in the op report procedure title, but the body of the report doesn't contain the documentation to support the extensive blepharoplasty CPT code 15823. The documentation of excessive skin weighing down the lid or a superior visual field obstruction will support 15823 — without this documentation, assign code 15822. Use 15823 for an upper eyelid blepharoplasty that's performed for the removal of excess, redundant skin from the upper eyelid. This fold of skin may mechanically weigh the lid, causing it to droop and obscuring the superior portion of the visual field. Often removal of this fold of skin will lead to resolution of any eyelid drooping. Blepharoplasty often includes the removal of orbital fat as well as the excess skin.

Acute vs. Chronic Rotator Cuff Tear
Without the proper documentation regarding the acuity of the tear, the coder won't know which of the two CPT codes available for an open rotator cuff repair to assign to the case.

The AMA hasn't published official guidelines regarding the "acute" and "chronic" references in these codes. Work closely with your orthopedic surgeons to develop guidelines for acute and chronic rotator cuff tears. If the patient has degeneration in the rotator cuff area, you may assign the "chronic" repair code 23412. Be sure to assign a chronic rotator cuff tear diagnosis code (726.10) if you report CPT code 23412 (repair of ruptured musculotendinous cuff open; chronic), or assign an acute rotator cuff tear diagnosis code (840.3, 840.4, 840.5 or 840.6) if you report CPT code 23410 (repair of ruptured musculotendinous cuff open; acute).

Distal Radius Fracture Fragments
When surgeons perform an open reduction of a distal radius fracture, many don't specify whether the fracture is extra-articular or intra-articular. When it is intra-articular, many don't specify the number of fragments that are fixated. No CPT code can be assigned until this information is provided and documented. If the fracture extends into the joint, it's intra-articular; if it doesn't, it's extra-articular. Here are fracture codes:

• 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 2 fragments
• 25609. Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments

Flexor Tendon Zone Repair
Some physicians don't specify the flexor tendon zone being repaired during hand cases. CPT codes 26350 to 26358 are zone-specific. Without the proper documentation, many coders default to codes that state "not in zone 2," when in fact these codes may or may not be correct. "No man's land" is the critical area from the mid-palm crease to the distal interphalangeal joint. This anatomical site impacts the assignment of the following codes:

• 26350. Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (no man's land); primary or secondary without free graft, each tendon
• 26352. Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (no man's land); secondary with free graft (includes obtaining graft), each tendon
• 26356. Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (no man's land); primary, without free graft, each tendon
• 26357. Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (no man's land); secondary, without free graft, each tendon
• 26358. Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (no man's land); secondary, with free graft (includes obtaining graft), each tendon

Long or Short Saphenous Veins
Physicians often don't specify "short" versus "long" when performing saphenous vein ligation, division and stripping. Without this information, the case can't be coded with 37718 (ligation, division, and stripping, short saphenous vein) or 37722 (ligation, division, and stripping, long [greater] saphenous veins from saphenofemoral junction to knee or below). The short saphenous vein runs from the ankle, along the calf and joins the popliteal vein behind the knee (sapheno-popliteal junction). The long saphenous vein runs from the ankle, along the inside of the leg and joins the deep vein in the groin (sapheno-femoral junction).

Internal vs. External Hemorrhoids
Many physicians don't specify internal or external hemorrhoids in their op reports. All of the hemorrhoid surgery CPT codes contain internal or external hemorrhoid references in their descriptions. Assign the CPT code(s) below based on the type of hemorrhoid treated and the technique used for treatment. Also be sure to assign the appropriate diagnosis code for the external and/or internal hemorrhoids.

• 46230. Excision of external hemorrhoid tags and/or multiple papillae
• 46250. Hemorrhoidectomy, external, complete
• 46255. Hemorrhoidectomy, internal and external, simple
• 46257. Hemorrhoidectomy, internal and external, simple; with fissurectomy
• 46258. Hemorrhoidectomy, internal and external, simple; with fistulectomy, with or without fissurectomy
• 46260. Hemorrhoidectomy, internal and external, complex or extensive
• 46261. Hemorrhoidectomy, internal and external, complex or extensive; with fissurectomy
• 46262. Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without fissurectomy
• 46320. Enucleation or excision of external thrombotic hemorrhoid
• 46934. Destruction of hemorrhoids, any method; internal
• 46935. Destruction of hemorrhoids, any method; external
• 46936. Destruction of hemorrhoids, any method; internal and external

Penile Adhesions
During the lysis of penile adhesions, many physicians don't document whether the adhesions are "post-circumcision" adhesions, critical information that impacts the CPT code assignment.

• 54162. Lysis or excision of penile post-circumcision adhesions
• 54450. Foreskin manipulation including lysis of preputial adhesions and stretching

Hypospadias Repair
Many physicians don't clearly document the surgical technique used to perform one-stage distal hypospadias repairs. Four CPT codes are available, so this information is critical for accurate coding. Only one of the following codes can be assigned per operative session, so you must clearly document the technique you use:

• 54322. One stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (Magpi, V-flap)
• 54324. One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps (flip-flap, prepucial flap)
• 54326. One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps and mobilization of urethra
• 54328. One stage distal hypospadias repair (with or without chordee or circumcision); with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap

Size of Uterus Removed
Pathologists often don't document the size of the uterus on the pathology report for laparoscopic hysterectomy cases. Without this information, many coders simply default to the code for "uterus 250g or less" when in fact the code may or may not be correct. Assign the appropriate laparoscopic hysterectomy CPT codes based on the surgical technique and the weight of the uterus removed:

• 58541. Laparoscopy, surgical, supracervical hysterectomy, for uterus 250g or less
• 58542. Laparoscopy, surgical, supracervical hysterectomy, for uterus 250g or less; with removal of tube(s) and/or ovary(s)
• 58543. Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250g
• 58544. Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250g; with removal of tube(s) and/or ovary(s)
• 58550. Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250g or less
• 58552. Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250g or less; with removal of tube(s) and/or ovary(s)
• 58553. Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250g
• 58554. Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250g; with removal of tube(s) and/or ovary(s)

Multiple Epidural Electrodes
Lots of physicians don't document the use of one site or separate sites to percutaneously place two neurostimulator electrodes. Without this information, coders may default to the assignment of one CPT code, 63650 (percutaneous implantation of neurostimulator electrode array, epidural), when two codes may be appropriate. You can report CPT code 63650 twice when two neurostimulator electrode catheters are placed through two separate sites. The CPT coding system makes no distinction as to the number of sites required for the placement of electrode catheters.

Post-operative Anesthesia
Numerous physicians document the performance of nerve blocks — in addition to the administration of general anesthesia — but don't document why they performed the nerve block. If they give the block for post-op pain management, you can report the block with a separate CPT code. When you administer general anesthesia and give pain management injections for post-op analgesia, they are separate and distinct services and are reported in addition to the anesthesia code. Whether the block procedure (insertion of catheter, injection of narcotic or local anesthetic agent) occurs pre-operatively, post-operatively or during the procedure is immaterial. For example, if a patient receives general anesthesia for arthroscopic ACL reconstruction and a femoral nerve block for post-op pain control, assign code 64447 (injection, anesthetic agent; femoral nerve, single) in addition to code 29888 for the ACL reconstruction.