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Periprosthetic fracture hip coding guestion

  1. #1
    Columbus, Ohio
    Question Periprosthetic fracture hip coding guestion
    Medical Coding Books
    Hello coders, I have a hip surgery that I have several questions about. The notes are below. Could this be coded as an arthroplasty revision, femoral component only 27138? Would the bone graft be included? Then the intertrochanteric fracture would be 27244 . Is the proximal femoral shaft fracture the same as the femoral head 27269? Or should the prothesis removal be coded separately 27090 with the hemiarthroplasty 27125? I think the more I read it, the more I'm confusing myself. Thanks, Paula

    1. Left hip bipolar hemiarthroplasty using DePuy Solution System, size 13.5-
    mm bowed large statured stem, Press-Fit, with a metal bipolar head 50
    outer diameter, 28-mm inner diameter, +1.5 length.
    2. Open treatment, left proximal femur greater trochanter, intertrochanteric
    region fracture with internal fixation using a Zimmer cable-ready grip
    system with trochanteric plate and bone grafting using femoral head
    3. Open treatment, left proximal femoral shaft fracture with internal
    4. Open removal of hip prosthesis, left hip.

    A long lateral incision was created through the skin with a scalpel. Blunt
    retractor was placed in the wound. All hemostasis was obtained throughout the
    case with Bovie. Dissection was taken down to the iliotibial band. This was
    split in line with the incision. A Charnley retractor was placed in here.
    The patient did have some scarring posteriorly from a prior posterior approach
    from his hip prosthesis. It was not known when the patient had the surgery.
    This was released with the Bovie. The gluteus medius muscle and tendon were
    seen. The anterior 1/3 of the muscle was split with a Bovie, and the cuff of
    tissue was widened. This was subperiosteally dissected off the proximal femur
    in the greater trochanteric region, leaving a cuff of tissue for later repair.
    This revealed the fracture in the intertrochanteric region. The gluteus
    minimus and capsule were split in line with this and subperiosteally dissected
    off the proximal femur. The patient had a significant amount of scar from
    prior surgery. The femur was subperiosteally dissected. I was rotating the
    femur out as I was dissecting down. The incision had to be extended down the
    shaft. It was seen that the fracture actually involved the proximal femoral
    shaft, and there was a separate frag fracture of the greater trochanter
    . The
    implant was dissected out with the Bovie. This was obviously loose. I backslapped
    the femoral head, and this loosened the Morse taper. The head was
    removed. This sized to 50 mm. The stem was removed after dissecting out the
    soft tissues. Again, I subperiosteally dissected the soft tissue off the
    proximal shaft. I cleared off the fracture site of the shaft, which was long
    and oblique, with curettes. I approximated and reduced the shaft
    anatomically. I placed 3 Zimmer cerclage wires and cables around this piece
    using the instrumentation from Zimmer. These were tightened, and then the
    screw was engaged, and then they were cut. This fixed the femoral shaft
    fracture anatomically.
    The patient also had bone loss proximally on the intertrochanteric region. I
    did choose a Press-Fit stem that was long. This was over 230 mm in length. I
    using the instrumentation from Zimmer. These were tightened, and then the
    screw was engaged, and then they were cut. This fixed the femoral shaft
    fracture anatomically.
    The patient also had bone loss proximally on the intertrochanteric region. I
    did choose a Press-Fit stem that was long. This was over 230 mm in length. I
    chose a DePuy Solution stem. I reamed to 14.5 mm. I chose a 13.5 diameter
    long DePuy Solution Press-Fit stem. This was a bowed stem. This was placed
    down, trying to keep the prosthesis in 10-15 degrees of anteversion. I was
    able to seat this on the calcar region proximally. The lesser trochanter was
    fixed with the proximal shaft. Once this was completed, I had to bur out the
    greater trochanter to allow the prosthesis to fit. I placed the greater
    trochanter piece anatomically over the prosthesis to fix the greater
    trochanteric piece. I used a long claw plate by Zimmer with cables. The
    cables were passed around the femur with cable passers. The collar was placed
    on the greater trochanter and compressed inferiorly. One cable was secured
    proximally, and one was secured distally with the inserter after tensioning
    and locking screws. The remainder of the cables were then secured down in a
    similar manner. The screws were all locked. I did take some femoral head
    bone graft and cut this down to size. I placed this in the defect anteriorly
    on the greater trochanter from bone loss. These were held onto the cables.
    There were 2 large pieces. I tightened these cables down as well, and then
    cut the cables after tensioning. The 50-mm outer diameter and 20-mm inner
    diameter bipolar head of +1.5 was trialed. I palpated the patient's leg
    lengths underneath the drape of the opposite leg. They appeared to be equal.
    The patient had good stability in range of motion. This was a bipolar head
    that I chose. I tapped this on and placed, again using Morris taper. I
    reduced this, and this was very stable. There was good fixation of the
    fractures and good position of hardware.

  2. #2
    Columbus, Ohio
    Good morning coders, I didn't get any replies yesterday, maybe today will be better. Happy St. Patrick's Day, Paula

  3. #3
    27236 for the bi-polar hemi
    27507 for the femoral shaft

    Removal of hardware for this case is incidental as he had to remove the hardware in order to fix the fractures.

    27244 forthe troch fracture is mutually exclusive to 27236 according to the CCI edits so thats not codeable either.

    hope this helps
    Mary. CPC, COSC

  4. #4
    Columbus, Ohio
    Mary, thanks so much for the clarification. I keep making them more complicated or you just make it seem easier (probably the latter). Thanks again, Paula

  5. #5
    Temple, TX
    Remember, you cannot bill the hemiarthroplasty 27125 when you are performing fracture care. There is a great article in Coding Alert that exlpains this.

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