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Difficult Hip sx...Help

  1. #1
    Question Difficult Hip sx...Help
    Medical Coding Books
    This pt had an infected total hip and my doctor removed the prosthesis and inserted antibiotic spacer about 6 months ago. He then did the following procedure...

    PO DX: 1.revision total hip arthroplasty w/x-rays
    2. ORIF of distal femur fx w/bone graft specifically femoral allograft and cables.
    3. ORIF of trochanteric fx with #5 Mersilene tape.
    4. Extensive excision of heterotopic bone of the rt hip.

    Procedure: ...prepped and draped in normal sterile fashion. Following the existing incision and ellipticating the existing scar, careful dissection was carried out down to the tensor fascia lata which was incised and retracted. With a great amout of difficulty the tensor fascia lata was separated from the existing tissue beneath it. Immediately following the existing bone and heterotopic bone and taking at least 2-2.5 hour time period, the existing heterotopic bone was removed from the acetabulum, the proximal femur, all the way to the anterior aspect of the acetabulum and superior portion of the acetabulum as well. This was done very carefully and meticulously. Once finished during the course of this an iatrogenic fx was necessary in the pts trochanteric region to do this. We then subsequently completed the removal of the five existing antibitic beads. One the acetabulum was identified, we started reaming and broaching for a #60 cup, with one single 30mm screw the cup was then secured into place with the liner. The version was 45 degrees and 20 degrees respectively. At this point the pts femur was addressed, untilizing an anterior approach to this point since the osteotomy was performed, we removed existing cement from the canal and then started reaming. The pt's bone was so weak and because of the curve associated with the femur, a second distal femur fx was created with the reamers. This was immediately addressed with a distal femoral graft and three cables.Care was taken again not to incorporate within the cables the popliteal vessels. This seemingly gave me excellent coverage of the existing fx and we then continued to address the pt's femur. Utilizing a tumor prosthesis, the longest one that they had on staff which was 125 with the proximal stem, we trialed, trialing lead to the need for at least another centimeter bone cut proximally. We removed the trial components and inserted the bone cement spacer which was actually too small and then cemented in the sterile tumoral stem. Once the bone hardened, in the interim we noticed that the pt had become a little bit tachycardiac and significantly hypotensive. This was treated for by anesthesia accordingly. This is also by the way not unusual for the pt's stature and health since he has had this problem in the past.

    We then reduced the pt's femur. We then reanastomosed the pt's trochanter back to pt's proximal femur w/a #5 Mersilene suture with a #2 Tycron suture, and reanastomosed the lateral vastus lateralis back to its origin as well. We then reanastomosed all the faxcia with #1 Vicryl sutures subcutaneous tissues with 2-0 vicryl suture and skin w/staples. Irrigating out coiously during the case and the closure with antibiotic solution. The difficultly of this case was significant, as many revisions as I have done this took approxiamately with x-ray time being another half hour to 45 minutes about 4.5 to 5 hours.

    Can anyone help me with this one??
    Thanks so much!

  2. #2
    I'll toss out some "hints" (I have not read this in detail nor have I checked cci edits)

    Look at

    (dont worry about the fractures that THE SURGEON created..those are considered incident to since he had to break them in order to do the hip replacement, also the osteotomy is included in the 27134).

    This case appears also to qualify for the 22 modifier based on the documentation.

  3. #3
    Thanks so much for your "hints". I was concerned about the created fractures. I was't sure if we could bill for those. This helps so much!!
    Thanks again!

  4. #4
    unfortunately not, but he can capture additional payment with the 22

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