Orthopedic Coding Alert

Total hip replacements (THRs) are one of the most commonly performed orthopedic surgeries. Yet these "routine" procedures are often accompanied by unusual circumstances or conditions such as congenital or developmental hip dislocations or previous hip surgery. Correct coding may involve more than the basic THR code. Knowledge of additional codes and proper modifier usage are critical to reimbursement for these costly reconstructions.

Total or partial hip replacements that occur without complication or additional procedures are coded with one of the following:

27125 hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)

27130 arthroplasty, acetabular and proximal femoral prosthetic replacement total hip replacement), with or without autograft or allograft

27132 conversion of previous hip surgery to total hip replacement, with or without autograft or allograft.

As with most major surgeries, there are related procedures that are considered a normal part of the procedure. According to the American Academy of Orthopedic Surgeons (AAOS) Complete Global Service Data Guide, the following are normally  bundled into the global service package for 27125, 27130 and 27132:

27005 tenotomy, hip flexor(s), open (separate procedure)

27033 arthrotomy, hip, including exploration or removal of loose foreign body

27140 osteotomy and transfer of greater trochanter (separate procedure)

27266 closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia

27071 partial excision (craterization, saucerization) (e.g., osteomyelitis or bone abscess); deep (subfascial or intramuscular)

27275 manipulation, hip joint, requiring general anesthesia.
 
 
Also, 27030 (arthrotomy, hip, with drainage [e.g., infection]), 27052 (arthrotomy, with biopsy; hip joint) and 27054 (arthrotomy with synovectomy, hip joint) are used for hip arthrotomies and are included with 27130 and 27132. Code 27125 also includes 27120 (acetabuloplasty).
 
Insertion of femoral components, with or without methyl methacrylate, is also part of the hip arthrotomy.
 
A few procedures often performed with hip arthroplasties are coded separately from the major code:
  

Tenotomy, adductors (codes 27000-27003)
 

Harvesting and insertion of bone graft from distant site (20900, 20902) (for 27130 and 27132 only)   
 

Intertrochanteric/subtrochanteric femoral osteotomy (27165) for 27132 only.

The above rules apply to routine, uncomplicated hip arthrosplasties. When arthroplasties are nonroutine, coders have to look beyond basic AMA and AAOS rules to determine what they can and can't legitimately bill. Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., provides several examples of hip arthroplasties performed by surgeons that fall outside "the norm" and require special coding consideration.

Example 1: The patient underwent a previous subtrochanteric osteotomy for slipped capital femoral epiphysis. Over the years she developed degenerative joint disease of the hip and required total hip arthroplasty. This case was complicated by significant anatomic abnormalities from her previous osteotomy as well as the presence of previously placed hardware. The surgical procedure included a repeat subtrochanteric osteotomy
 
Coding the Surgery: 27132 is reported for the THR, but 27165 should also be reported. Modifier -51 (multiple procedures) should be used with carriers that still require it.
  
Coding Tip: Stout says that any patient with a history of hip surgery may present an opportunity to report additional CPT codes. "Careful review of the operative report is a must," she says. When reporting 27132, AMA rules dictate that removal of previously placed hardware and takedown of a prior osteotomy or fusion should not be reported in addition to the code for the conversion.

  
Example 2: The patient has longstanding degenerative joint disease of the hip secondary to developmental hip dysplasia. The case was complicated by congenital abnormalities of the acetabulum, requiring acetabular reconstruction.
 
Coding the Surgery: The primary code for the surgery is 27130. However, the complexity of the surgical procedure warrants appending modifier -22 (unusual procedural services) to 27130.
 
Coding Tip: Primary total hip arthroplasty on a patient with a congenital or developmental hip dislocation is likely to be complicated. A careful review of the operative report may yield the opportunity to report additional procedures or append modifier -22.
  
Example 3: The patient has a history of  femoral neck fracture treated with open reduction with internal fixation that has gone on to nonunion. A right hip hemiarthroplasty was performed. Review of the operative report reveals that an adductor tenotomy was performed, and  hardware was removed.
 
Coding the Surgery: The primary code is 27125. But by reviewing the operative report, the coder was able to confer with the surgeon and determine that 27001 and 20680 (removal of implants; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]) could also be reported, using modifier -51 (multiple procedures) if required.
 
Coding Tip: A patient with a history of previous surgery and/or injury to the hip region will always present a surgical challenge. A review of this patient's operative report revealed the opportunity to report (27001) and hardware removal (20680).
 
"What we're stressing here is the need for the coder to review the operative report to determine if anything was unusual about the case," Stout says. "Whenever one of my hip surgeons reports only 27130 and the diagnosis is congenital hip dislocation or developmental hip dislocation, I always check the operative report to see if there are any other coded services." Congenital and developmental anomalies associated with the hip often demand a level of service outside the norm.
 
Notes on Bone Grafting

The CPT description for 27130 and 27132 includes the language with or without autograft or allograft. This may lead coders to conclude that bone graft procedures should not be reported as an additional code. This is true in the case of allograft (donor) bone or locally harvested bone, i.e., from the excised femoral head. However, when the graft is harvested from a distant site via a separate incision, the AAOS advocates reporting 20900 or 20902 in addition to the hip arthroplasty code.

Orthopedic coders routinely refer to the AAOS Complete Global Service Data Guide as the "bible" of orthopedic coding. The book lists every CPT procedure related to the musculoskeletal system, and indicates which items are bundled and which are billable separately. Although the Correct Coding Initiative (CCI) CMS' quarterly list of code edits is often more restrictive than AAOS, coders should still report services that Medicare might deny, but that the AAOS would support reporting. Even if Medicare denies the claim, AAOS provides a sound basis for an appeal. For private carriers that normally follow the CCI edits, the chance of a successful appeal is higher.
 
There is always the chance that the CCI edits may change, opening the door for you to rebill previously denied services. When considering this approach with Medicare or non-Medicare payers, coders should ask the surgeons whether they want to attempt to charge for work that is out of the ordinary for the primary procedure.
 
For example, CCI includes soft-tissue biopsy procedures (27040, biopsy, soft tissue of pelvis and hip area; superficial; 27041 ... deep, subfascial or intramuscular) in 27125 but AAOS does not. Stout's surgeons agree that if the biopsy is taken from the operative field, it should be included. However, if a separate incision was required or the incision had to be extended for a biopsy, this should be a separately reportable service with modifier -59 (distinct procedural service) appended.
  
CCI bundles bone grafting 20900 and 27170 (bone graft, femoral head, neck, intertrochanteric or subtrochanteric area [includes obtaining bone graft]) into 27130, while AAOS does not. Stout's surgeons support the AAOS position that bone grafts harvested from a distant site should be reported in addition to the arthroplasty code. According to Stout, "Preparation of allograft materials often requires a great deal of work, and the surgeons feel that in some instances it may warrant the use of modifier -22."
 
CCI treatment of acetabular fractures is always bundled with 27130. Stout's surgeons agree that if the fracture treatment is accomplished using the standard acetabular components, no additional code should be reported. However, if additional hardware is needed, one of the following codes should be reported for treatment of the fracture:

27226 open treatment of posterior or anterior acetabular wall fracture, with internal fixation

27227 open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, with internal fixation

27228 open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture, with internal fixation.