Coding hip procedures
Some procedures require careful code selection
By Margie Scalley Vaught, CPC, CPC-H, CCS-P, ASC-OR; Kevin Bozic, MD; Richard Friedman, MD; M. Bradford Henley, MD, and Frank Voss, MD
When it comes to services and procedures performed on the hip, care needs to be taken to ensure the correct code selection.
For coding purposes, the hip consists of the acetabulum, femoral head, femoral neck and trochanteric region (comprised of the greater and lesser trochanters and the subtrochanteric area). Although the femoral neck is only about 2 inches long, four separate ICD-9 codes can be selected that relate to femoral neck fractures.
For closed femoral neck fractures, the choices are:
• 820.00—Intracapsular section, unspecified
• 820.01—Epiphysis (separation) (upper); Transepiphyseal
• 820.02—Midcervical section; Transcervical not otherwise specified (NOS)
• 820.03—Base of neck; Cervicotrochanteric section
• 820.09—Other; Head of femur; Subcapital
Orthopaedic surgeons must clearly state and document the precise location of a femoral neck fracture to support the most specific ICD-9 code available under the ICD-9 Coding Guidelines.
Hip Core decompression
Hip core decompression is used for avascular necrosis of the femoral head and involves removing a plug of bone from the involved area. It is applicable to patients with a mild to moderate degree of involvement that has not yet progressed to collapse. Because the procedure creates a hole in the bone, increasing stress on the proximal femur, six weeks of protected weightbearing is often necessary to avoid fracture.
Currently, no CPT code exists that describes the full work performed in a hip core decompression. The American Medical Association’s CPT guide states that this procedure should be reported using the unlisted code, 27299. There are several codes, however, that could represent components of this procedure. These include:
• 27071—Partial excision (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular)—which describes removal of the necrotic (dead) femoral head (of the hip socket) with special devices, creation of a core decompression area and obtaining autogenous cancellous bone.
• 20955—Bone graft with microvascular anastomosis; fibula—which represents the vascularized fibular graft procedure in which the fibula is harvested from the leg with its small attached blood vessels and transferred to the hip where microvascular anastomosis of four vessels is performed.
• 27170—Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft)—which covers placement/attachment of the fibular bone graft and cancellous bone graft into the cavity created in the femoral head.
The AAOS Coding, Coverage and Reimbursement Committee has also recognized that code 20225—Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur)—could be used again depending on what is actually being performed and documented (April 2004).
Many of these codes can be considered inclusive and/or bundled in the other codes under the Correct Coding Initiative. Under CPT guidelines, however, an unlisted code should be reported instead of codes that approximately represent the services rendered. In your cover letter for reimbursement purposes, you can liken the procedure to one or more of the codes listed above, depending upon the specific interventions performed.
Femoral head resurfacing
Initially, a femoral head resurfacing (FHR) procedure involves only the femoral head, not the acetabular “socket” of the hip joint. FHR involves implanting a metal hemisphere, which exactly matches the size of the native femoral head, over the bone. This is similar to capping a tooth when the root is still good, rather than pulling it and replacing it with a false tooth.
This procedure is designed to “buy time” for the younger individual whose extent of disease or degree of progression is such that one of the preservative procedures listed above cannot be performed. Over time, however, the metal head will wear out the socket, and a total hip replacement will be needed.
Most patients with osteonecrosis are under age 50, and a total hip replacement (THR) is unlikely to last the 30 or more years these patients will require. Therefore, it is possible that these patients will require at least two procedures during their lifetimes. A femoral head resurfacing followed later by a primary THR is preferable to a primary THR followed by a revision THR.
The correct reporting of this procedure can depend on the actual documentation and supporting information. Even though there is no reaming of the femoral canal, the femoral head is milled prior to capping it with a metal hemisphere. Since this is technically similar to a partial hip replacement, this procedure can support a hemiarthroplasty CPT code. There should be clear documentation of the work involved on the femoral head and the improvement in the patient’s condition to support the medical necessity. Surgeons should double check with their private carriers regarding contracted policies for coverage of FHR procedures.
Injection of the hip under fluoroscopic guidance
Before injecting steroids into the hip area, physicians often inject dye and perform an arthrogram to outline the joint and confirm that the needle location is in the joint capsule and no other pathology is identified. In this case it would be appropriate to report code 27093—Injection procedure for hip arthrography; without anesthesia—along with code 73525 for the interpretation of the arthrogram.
If a surgeon is just injecting the hip to confirm needle location and the intent is not an arthrogram, 76003 would be appropriate.
Radiologic imaging of the hip and pelvis
Q. Can code 73520 still be used to report a bilateral hip radiograph performed with two views on each side, even if an anteroposterior view of the pelvis is not also performed, or is it more appropriate to report code 73510 twice?
The AMA commented on this question in the April 2002 CPT Assistant:
“According to the American College of Radiology, an anteroposterior (AP) view of the pelvis, as well as additional views of both hips, is the appropriate method of examination when a bilateral hip study is ordered. In addition to the AP view of the pelvis, at least one more view of each hip, typically a coned-down frog-leg lateral view, is obtained amounting to three views: one AP view of the pelvis that includes both hips; one frog-leg lateral of the right hip; and one frog-leg lateral of the left hip.
“However, if a bilateral study is performed without an AP view of the pelvis, then code 73520 (Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis) may be reported with modifier -52 (Reduced services) appended to indicate that the study was not performed in its entirety. CPT code 73510 (Radiologic examination, hip, unilateral; complete, minimum of two views) is not intended to describe a bilateral hip study, but a complete radiological examination with a minimum of two views performed on a single hip.
“If right and left hip studies are separately ordered and performed, and there are separate interpretations and written reports signed by the interpreting physician, then it would be appropriate to report the code 73510 two times. In this case, modifier -59 (Distinct procedural service) should be appended to the second code to indicate that it is a distinct procedure.
“Since modifiers are carrier-specific, it is recommended that the provider check with their local carrier and other third-party payers for their guidelines on the use of modifiers.”
Chondroplasty and abrasion arthroplasty hips
Q. What code is reported when both a chondroplasty and abrasion arthroplasty is performed on the right hip using arthroscopic technique?
When this procedure is performed via arthroscopy, the appropriate code is 29862—Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum. This code represents the drilling, debridement and abrasion arthroplasty performed via arthroscope. It is inappropriate to report this code multiple times for the different components of the code performed in the same hip joint.
Revision of poly liner
Q. How do I report the removal/exchange of the acetabular polyethylene liner along with revision of the femoral head?
This would fall under revision two-component code 27134—Revision of total hip arthroplasty; both components, with or without autograft or allograft—with modifier -52 appended. The appropriate ICD-9 code would be 996.46—Articular bearing surface wear of prosthetic joint—that became effective Oct 1, 2005.
The new ICD-9 procedure codes referenced in “Using the new revision TJA codes” (August 2005 Bulletin) are facility-based codes, not to be reported by the surgeon. Orthopaedic surgeons should continue to use the appropriate CPT codes when performing revision surgery.
To report intramedullary rodding of the metacarpal bones when the technique is performed percutaneously and the fracture site is not opened, use codes such as 26608 or 26727 (not 26607).
M. Bradford Henley, MD, is chairman of the AAOS Coding, Coverage and Reimbursement Committee. Kevin J. Bozic, MD, Richard J. Friedman, MD, and Frank R. Voss, MD, are members of the committee.
Margie Scalley Vaught, CPC, CCS-P, CPC-H, ACS-OR, is an independent coding specialist and BONES member who has served on the National Advisory Board for the American Academy of Professional Coders. She can be reached at firstname.lastname@example.org