Orthopedic Coding Alert

Some payers want to see what you’ve done before opting for 27125, 27130.

Coders that are reporting partial or total hip replacements might want to check with their payers to see if there’s a documentation requirement for 27125 (Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)) or 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft).

Then, they’ll have a better idea of just what the payer wants to make those claims successful.

For example, “many insurance companies require conservative treatment prior to making the decision for hip replacement,” confirms Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior coding educator at Healthcare Information Services in Park Ridge, Illinois. “This would include joint injections of cortisone and physical therapy. Many insurance carriers also have a time requirement for conservative treatment.”

This is confirmed by coder Megan Szczepanski, CPC-A. For hip replacements, “Highmark BCBS wants to see conservative treatment for three months and chronic, severe, disabling pain for at least six months, along with other factors.

“The patient would likely need to be preauthorized for these surgeries by their insurances. Whether they meet the qualifications for meeting their insurance standards for paying should be reviewed at that time,” Szczepanski adds.

Bottom line: Anytime the surgeon replaces a joint, “it’s a good idea for the operating surgeon to indicate in his op note any more conservative treatments — injections, PT [physical therapy], etc.,” says Denise Paige, CPC, COSC, an orthopedic coder with Bright Health Physicians in Whittier, California:

Consider These Elements When Documenting Previous Tx

If the payer you are coding for requires proof of previous treatment attempts in order to justify 27125 or 27130, your documentation could note the following, according to Denise Caposella, CPC, senior consultant at Acevedo Consulting Incorporated in Delray Beach, Florida:

• Unsuccessful conservative therapy (nonsurgical medical management).
• History of a reasonable attempt (usually three months or more) at conservative therapy as appropriate for the patient in their current episode of care.
• Documented trial of nonsteroidal anti-inflammatory drugs (NSAIDs) or contraindication to such therapy and/or documented supervised physical therapy.
• Evidence that activities of daily living (ADL) are diminished due to pain and/or disability despite non-surgical medical management.

Also: “Keep in mind that each payer may have specific clinical indications for these procedures,” warns Paige.

Patients Often Suffer Fractures, Arthritis Prior to Procedure

When you are documenting your hip replacement claim, you want to be sure that you paint the most complete picture possible of the patient, the situation, and the types of treatments that might have preceded the surgery.

To ensure the cleanest claim possible, you need to know the exact condition that afflicts your hip replacement patient. Some of the conditions that might warrant a hip replacement surgery include:

• Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur: C40.2- (Malignant neoplasm of long bones of lower limb), C47.2- (Malignant neoplasm of peripheral nerves of lower limb, including hip), C49.2- (Malignant neoplasm of connective and soft tissue of lower limb, including hip).
• Avascular necrosis (osteonecrosis of femoral head): M87.- (Osteonecrosis).
• Hip fractures: M80.- (Osteoporosis with current pathological fracture), M84.- (Disorder of continuity of bone).
• Advanced joint disease (arthritis): M05.- (Rheumatoid arthritis with rheumatoid factor) through M08.- (Juvenile arthritis), M12.- (Other and unspecified arthropathy), M13.- (Other arthritis).
• Degenerative condition: M16.- (Osteoarthritis of hip), M16.11 (Unilateral primary osteoarthritis, right hip), M16.12 (Unilateral primary osteoarthritis, left hip).
• Fracture: S72.141- (Displaced intertrochanteric fracture of right femur), S72.142- (Displaced intertrochanteric fracture of left femur).

Note: This is a not list of payer-approved ICD-10 codes for 27125 and 27130; these are merely the types of conditions your patients who receive hip replacements might have. As with every claim, you need to check your payer’s policy to see what its diagnosis — and documentation — rules are for hip replacement claims.