Orthopedic Coding Alert

CPT does not include a code specifically for femoral head resurfacing (FHR), which means selecting the most appropriate code can be tricky. All isn't lost, however, when you know how to pick the correct diagnosis and ensure your surgeon practices clear documentation.

From a coding perspective, the hip consists of four regions: the acetabulum, femoral head, femoral neck, and trochanteric region. And although the femoral head is only approximately 2 inches long, ICD-9 includes four separate choices for closed femoral neck fractures:

• 820.00 -- Transcervical fracture, closed; intracapsular section, unspecified

• 820.01 -- ... epiphysis (separation) (upper)

• 820.02 -- ... midcervical section

• 820.03 -- ... base of neck.

The more specific your orthopedist is with his diagnosis,the more specific you can be with your coding.

Many patients with osteonecrosis (733.4x, Aseptic necrosis of bone ...) are under age 50, which makes total hip replacement a less-than-ideal option because the components might not last the 30 or more years of the patient's lifetime. That's why your orthopedist might opt for femoral head resurfacing instead (also known as Birmingham hip resurfacing).

The surgery is technically similar to a partial hip replacement, says Judy Larson, CPC, billing manager for Rockford Orthopedic Associates in Rockford, Ill. Because of this, some payers such as Aetna and Cigna, recognize 27125 (Hemiarthroplasty, hip, partial [e.g., femoral stem prosthesis, bipolar arthroplasty]) if you meet the payer's selection criteria.

Tip: Check the payer's policy to verify acceptance of 27125. Then double check your documentation for clear notes regarding medical necessity.

Prepare to Fight Potential Denials

Some payers consider FHR as investigational, so enact non-coverage policies. Because of this, check each of your payers' websites for policies that disallow coverage.

"Billing the services with the standard codes will most likely get you paid, but if the insurance company ever performs a retroactive review, they might take back money they paid for the service, based on the non-coverage or conditions of coverage policy that was in effect," warns Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, coding and compliance supervisor with Proliance Orthopedics and Sports Medicine in Bellevue, Wash.

If the payer in question has a non-coverage or conditions of coverage policy for FHR, keep a few tips in mind throughout the claims process. First, obtain a fullpre-surgical review based on the patient's medical records and supporting documentation for medical necessity approval. "Do not allow carriers to tell you in these cases that there's no need for preauthorization for medical necessity," Stumpf says. "Do all you can to force a full review of documentation."

Next, track all pertinent preauthorization documentation including the reference ID numbers for payer phone calls, the member of the payer's staff you discussed the case with,letters from the payer, preauthorization numbers, and any other documentation supporting their approval.

Finally, get the patient to sign an advance beneficiary notice (ABN). "I encourage the patient to call and obtain his own reassurance of coverage," Stumpf adds. Tell the patient to document all pertinent information regarding the call for his records and to be prepared to submit that documentation if the need arises.

Bottom line: All these steps involve extra work for your staff and the patient, but can pay off in the end. "I've had too many carriers state that they have the right to retroactive review and take back monies paid, regardless of the work done on the front end," Stumpf says. "If the documentation is strong and bullet proof, the provider will be successful in overturning these take-backs or retroactive reimbursement denials."