Orthopedic Coding Alert

Question: Our patient had a hip replacement and returned one year later for a routine follow-up with an x-ray. We plan on reporting 99213 with ICD-9 code V43.64, but according to the ICD-9 handbook, V43.64 is a secondary code. Which primary code should we report for this diagnosis? 


Indiana Subscriber

Answer: If an asymptomatic patient presents to your practice for an annual visit following total hip replacement, you should report the appropriate E/M code (99211-99215 for established patients), along with V67.09 (Follow-up examination; following other surgery) and V43.64 (Organ or tissue replaced by other means; hip).

If the patient is still healing from the surgery, you should report V54.81 (Aftercare following joint replacement) instead.

Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC; and Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopedic Associates in Durham, N.C.