When is hip revision surgery not hip revision surgery?
Staged procedures require different coding
By Margaret M. Maley RN, MS
Modern revision surgery techniques pose a difficult challenge to reconstructive orthopaedic surgeons. Coding these cases does not need to be complicated, but both surgeons and business office personnel must understand the definition of hip revision surgery and the use of the modifier –58.
The removal and replacement of an arthroplasty as the definitive procedure during the same operative session is considered joint revision surgery. But neither part of a staged procedure—in which the surgeon removes the hip prosthesis and inserts cement or prosthetic spacer in one session and later removes the spacer and replaces it with the definitive prosthesis—should be coded as revision total hip arthroplasty (27134).
The proper way to report this staged procedure is shown in Figures 1 and 2. Figure 1 shows the reporting for the first stage of the surgery; Figure 2 shows the reporting for the second stage.
The Relative Value Units (RVUs) are higher for the conversion code 27132 (42.99 RVUs) than for the total hip arthroplasty (THA) code (36.93 RVUs). This recognizes that conversion of previous hip surgery is more difficult than a primary THA, because the surgeon must operate through an altered surgical field with scarring.
The modifier –58 is attached to a related procedure performed in the postoperative or global period. The modifier is appended to the CPT code for the subsequent procedure to indicate that the subsequent procedure was:
• planned prospectively at the time of the original procedure (staged) or
• subsequent surgery that is more extensive than the original procedure or
• for therapy following a diagnostic surgical procedure
Medicare has assigned a 90-day global period to joint removal and revision surgery. This means that any surgery done during the global period requires the use of a modifier. Use modifier –58 if the subsequent procedure is “staged” (see above), modifier –78 if the subsequent procedure is to treat a complication that required a return to the operating room and modifier –79 if the procedure has nothing to do with the original procedure (such as open treatment of a wrist fracture three weeks after a THA).
Modifiers –58 and –78 cause the most confusion among surgeons and their billing staffs. Modifier –58 is never used to indicate the treatment of a surgical complication. Treatment of a surgical complication is indicated by using modifier –78. This notifies the payer of a return to the operating room for a related procedure during the postoperative period. The difference between these two modifiers is significant and must be understood. A comparison between modifier –58 and modifier –78 is shown in Figure 3.
There are five important issues to remember about the modifier –58:
1. No reduction in reimbursement for the subsequent procedure is expected when using the modifier –58.
2. The modifier –58 is only required if the second stage is done during the global period of the original case.
3. No modifier is necessary if the second stage is done after the global period of the first case has expired (i.e. 27123— conversion of previous hip surgery to THA done six months following 27091— removal of THA)
4. Each operative report should have a “history and indications” paragraph explaining the staging of the two procedures, as shown in figures 1 and 2.
5. The modifier –58 should not be used to indicate the treatment of a complication.
If you follow these suggestions, coding won’t be the most complicated part of joint reconstruction surgery.
Margaret M. Maley is a consultant with KarenZupko & Associates.