Orthopedic Coding Alert

Modifiers may make the difference for your difficult hip procedure claims

If your orthopedic surgeon performs total hip arthroplasty on a patient with a congenital or developmental hip dislocation, you may be entitled to addi-
tional reimbursement.
 
Our March article "Want to Ace Hip Procedure Coding? Here's How" elicited such a tremendous response from our readers that subscribers sent us dozens of additional hip coding questions. Read on to see how our experts advise tackling your toughest hip coding problems.

When Should You Append -22 to THA?

Question 1. Every time our surgeon performs a primary total hip arthroplasty on a patient with a congenital or developmental hip dislocation, he thinks we should append modifier -22 (Unusual procedural services) to the claim and request more money. Is this type of surgery generally complicated enough to warrant the modifier and additional reimbursement that the surgeon believes we can collect?

Answer: Most likely, yes. "Developmental hip dislocation involves an underdeveloped acetabulum, which necessitates more advanced techniques for reconstruction and oftentimes may require different implants compared to standard hip replacement for osteoarthritis," says Scott C. Wilson, MD, assistant professor of orthopedics at Tulane University School of Medicine in New Orleans.

If your surgeon performs a total hip replacement (27130, Arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip arthroplasty], with or without autograft or allograft) on a patient with developmental hip dislocation, you should check the operative report to determine whether the surgeon noted additional work. If so, you should ask him the percentage of extra work that he performed, and you can then increase your fee by that percentage.

Append modifier -22 to 27130 and send your insurer a letter with your claim, explaining why the physician believes the surgery was more complicated than a normal total hip arthroplasty. In addition, you should send your operative report with the claim.

How Many Codes Describe Hip Joint Debridement?

Question 2. Our patient suffered a severe hip joint infection following total hip arthroplasty, so the surgeon performed hip arthrotomy, then debrided and irrigated the wound. Can he bill both 11044 and 27030, or should he just bill 27030?

Answer: The answer depends on whether the surgeon debrided bone, or just tissue and/or muscle. If the surgeon does not document bone debridement, you should not report 11044 (Debridement; skin, subcutaneous tissue, muscle, and bone).

Because the surgeon did not document bone debridement, you're left with debridement code choices of 11040-11043. But "the American Academy of Orthopaedic Surgery's Global Service Data indicates that 'debridement, excisional, of soft tissue (e.g., 11040-11043) is included in 27030 (Arthrotomy, hip, with drainage [e.g., infection])," says Tracy E. Wheeler, CPC, coder at Albany Orthopedic Center in Albany, Ga.

When the surgeon performs debridement along with hip arthrotomy or other surgeries, "there must be clear documentation that he performed more than the normal amount of debridement during the procedure," says Susan Vogelberger, CPC, CPC-H, PMCC instructor and business office coordinator for the Orthopaedic Surgery Center at Beeghly Medical Park in Ohio. "Otherwise, I would not code the debridement separately."

In other words, reimbursement for the arthrotomy inherently includes any debridement that the surgeon performs in the immediate area of the surgical wound. If, however, the debridement necessitated extension of the incision and/or addressed a separate area, you could separately report a debridement code.

If you perform the arthrotomy during the global period of the original hip arthroplasty, you should append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to 27030, Wheeler says.

When Does a Femur Injury Warrant a Hip Fx Code?

Question 3. Our orthopedic surgeon documented a fracture to the intertrochanteric region of the femur. Should we report a hip fracture ICD-9 code or a femur fracture code? I'm not sure when a femur fracture becomes a hip fracture.

Answer: Before you assign an ICD-9 code, the physician must indicate which bony component of the hip your patient fractured (for example, the femoral head, femoral neck, acetabulum, etc).

"Generally speaking, a hip fracture refers to a fracture of the neck or intertrochanteric portion of the proximal femur," Wilson says. "True femur fractures usually involve the femur below the level of the lesser trochanter in the mid shaft area."

If your surgeon specifically notes a fracture to the intertrochanteric region, you should report the appropriate code from the femoral neck section of ICD-9.

If the patient had a closed fracture, you should report 820.21 (Fracture of neck of femur; pertrochanteric fracture, closed; intertrochanteric section). If the patient had an open fracture, choose 820.31 (... pertrochanteric fracture, open; intertrochanteric section).