Part B Insider (Multispecialty) Coding Alert

Published on Fri May 12, 2006 PDF

996.4 now includes a fifth digit

If you've been using 996.4 (Mechanical complication of internal orthopedic device, implant, and graft)--and receiving numerous denials--it's because you aren't using any of the new nine diagnosis codes that were released last October.

By now, your orthopedic practices should have a handle on the new prosthesis or implant complication diagnosis codes. Reason: These new codes are more specific and will help you better describe the causes of your patients' joint prosthetic joint implant problems. They include:

• 996.40--Unspecified mechanical complication of internal orthopedic device, implant, and graft
• 996.41--Mechanical loosening of prosthetic joint
• 996.42--Dislocation of prosthetic joint
• ICD9 996.43 --Prosthetic joint implant failure
• 996.44--Peri-prosthetic fracture around prosthetic joint
• 996.45--Peri-prosthetic osteolysis
• 996.46--Articular bearing surface wear of prosthetic joint
• 996.47--Other mechanical complication of prosthetic joint implant
• 996.49--Other mechanical complication of other internal orthopedic device, implant, and graft.

Caution: ICD-9 deleted the unspecific code 996.4 to make room for the more detailed codes. "Code 996.4 has been expanded to five digits, so we will now be able to report the specific mechanical complication of the orthopedic implant or device," says Leslie Follebout, CPC, coding department supervisor at Peninsula Orthopedic Associates PA in Salisbury, MD.

These new codes should paint a clearer picture for payors, so they can decrease their chances of having to resubmit claims, face requests for more information or appeal denials.

Example #1: You might use 996.43 if the actual prosthesis device broke, Follebout says, or if a locking ring on a total hip replacement broke.

Example #2: Code 996.45 would apply if the patient had osteolysis due to a prosthetic complication. "As the prosthesis begins to wear out, little pieces of the plastic liner will come off and be absorbed into the hip joint," explains Follebout.

"Osteolysis is the body's reaction to the presence of the microscopic pieces of plastic," Follebout says. "As the body absorbs the plastic, it also begins to absorb the bone, and the bone gets thinner."

When patients come back to the practice for x-rays status-post joint replacement surgery, although they may be asymptomatic, the physician will determine whether they suffer from bone that is so thin around the prosthesis that they are at risk of fracture. If so, you should report code 996.45.