Orthopedic Coding Alert

Use this code when the procedure includes femoral stem, neck only.

High-dollar surgeries such as hip replacements present a high-stakes challenge for coders when it’s time to file the claim.

If you undercode for these services, your practice could get less than deserved for the procedure; swing the other way and overcode, and your hip replacement claim will likely be replaced — by a denial.

To mitigate those potential mishaps, we’ve put together some hip replacement coding advice from behind-the-scenes experts and front-line coders. Here’s what they had to say.

Know What Separates Partial, Total

When the orthopedist performs hip replacement on a patient for the first time — meaning it isn’t a replacement prosthesis — you’ll often choose 27125 (Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)) for partial replacements and 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft) for full ones. There are some exceptions, but the majority of partial and total hip replacements are represented by these codes.

Explanation: “A partial hip replacement involves replacing just the femur with a femoral stem prosthesis or bipolar arthroplasty, where a total hip replacement is replacing the femur and the acetabulum with a prosthesis — the ball and cup of the joint,” relays  Lynn M. Anderanin, CPC, CPMA,CPPM, CPC-I, COSC, senior coding educator at Healthcare Information Services in Park Ridge, Illinois.

Coders should be careful not to confuse 27125 and 27130 with other hip prosthesis procedures, warns Megan Szczepanski, CPC-A. You’ll typically use 27125 and 27130 for hip replacements, but there are coding exceptions.

“When the reason for the femoral replacement is a femoral neck fracture, then you would code 27236 [Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement],” says Szczepanski. Also, “if the patient had a prior fracture that has now caused posttraumatic osteoarthritis and is now getting a THA [total hip arthroplasty], you would choose 27132 [Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft] instead of 27130,” she continues.

Best bet: Get to know all the hip replacement/prosthesis codes, but pay special attention to 27125 and 27130, as you’ll probably use these more often than other hip replacement codes.

 Look for Acetabular Component Involvement for 27130

When you’re staring at a hip replacement claim, make sure to check the provider’s op notes for a direct statement on the procedure type; it could save you a lot of work. “My surgeons generally specify in the ‘Name of the Procedure’ part of their op note which [hip replacement procedure] they are doing,” says Szczepanski.

If the notes are more opaque, then you can often use context clues to separate partial and total hip replacements. On 27125 claims, the provider only replaces the femoral head, “with no involvement of the acetabular component,” according to Denise Caposella, CPC, senior consultant at Acevedo Consulting Incorporated in Delray Beach, Florida.

For a total hip replacement, the orthopedist replaces both the femoral and acetabular components, says Denise Paige, CPC, COSC, an orthopedic coder with Bright Health Physicians in Whittier, California:

According to Caposella, notes for 27130 claims could include:

• “Removal of any osteophytes around the rim of the acetabulum;
• “Reaming out the acetabulum exposing both subchondral and cancellous bone;
• “Insertion of the acetabular component and femoral stem prosthesis;
• “Preparing the femoral canal with a reamer and rasp; or
• “Augmenting the area with an autograft or allograft.”

Pump Brakes Before Coding Additional Services

There are some services that could accompany a partial or total hip replacement; you should tread carefully, however, when considering coding any of these services/procedures separately, experts warn.

“I am not aware of any other procedures that may accompany a hip replacement and be separately billable,” says Caposella. “Code 27130 includes any bone graft harvest, which would not be separately billable. … 27130 includes closed, open, and percutaneous treatment of fractures and dislocations, which would not be separately billable.”

Also, the orthopedist could very likely perform a tenotomy during these surgeries — for example, 27000 (Tenotomy, adductor of hip, percutaneous (separate procedure)) or 27003 (Tenotomy, adductor, subcutaneous, open, with obturator neurectomy). Tenotomy is not a separately reportable service for 27125 or 27130, confirms Paige.