# Femoral neck fracture treated with percutaneous cement injection



## coffee2day (Jun 20, 2017)

Hello, any advice on what code to use for this procedure of percutaneous cement injection into femoral neck due to stress fracture? The closest code I'm coming up with are CPT 27235 percutaneous skeletal fixation femoral neck, but this involves pins and not cement. 

Any info would be greatly appreciated, thank you. 

 1. CT-guided biopsy of the femoral neck.
 2. Internal fixation of the femoral neck with bone cement.
 HISTORY: The patient with a 7-month history of right hip 
 pain, which likely started as a stress fracture. However, he has not been 
 healing despite multiple attempts to rest and nonweightbearing.
 DESCRIPTION OF PROCEDURE: 
 The right hip was prepped and draped in standard, sterile fashion. 
 Local anesthesia was performed with 2% lidocaine and bupivacaine.
 Preliminary CT was performed. Under CT guidance, a 9-gauge bone biopsy needle 
 was then introduced laterally into the femoral neck. The CT with multiple 
 reconstructions performed in the room confirmed position of the needle in the 
 right femoral neck. 
 Single biopsy was then performed. Subsequently, approximately 6 mL of bone 
 cement with hydroxyapatite were then injected in the femoral neck. We were 
 careful to avoid placing the cement too close to the cartilage. The cement was 
 injected under CT 
 guidance with multiple intermittent fluoroscopies. Postprocedure CT was then 
 performed demonstrating a good amount of cement in good position in the right 
 femoral neck. The patient tolerated the procedure well, and there were no 
 immediate 
 complications.
 INTERPRETATION: Preliminary CT demonstrated a small amount of periosteal 
 reaction in the lower portion of the femoral neck consistent with stress 
 fracture. No linear fracture was noted. CT confirmed position of the needle in
 the femoral neck. CT was 
 injected during cement administration. Post procedure CT demonstrated a good 
 amount of cement in the femoral neck without extravasation of cement.
 IMPRESSION: 
 1. Successful CT-guided biopsy of the abnormal area seen on the MRI in the 
 femoral neck.
 2. Successful internal fixation femoral neck with bone cement.​


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## Orthocoderpgu (Jun 22, 2017)

Unlisted code. 22510 seems to be the best comparison code since it's a similar procedure, just on a vertebral body.


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## AlanPechacek (Jun 24, 2017)

This whole scenario is complicated by the fact that a "femoral neck fracture" hasn't really been proven.  It has been "assumed" to be a Stress Fracture.  The preliminary CT Scan showed "a small amount of periosteal reaction in the lower portion of the femoral neck consistent with a stress fracture. No linear fracture was noted."  There is no description of any particular bony lesion within the femoral neck on the CT.  If there had been a MRI done, there is no reference to it or its findings.  Maybe the biopsy taken will answer this question when the final report is available, but unfortunately that may be inconclusive as to there being a "fracture."  If this proves to be a fracture, then the "Fracture Treatment" rendered by placing the cement would be justifiable.  But, if a fracture can't be proven, but only inferred from all the clinical data, then you have a problem.
     So far what you have is a deep bone biopsy of the femoral neck (20225) with CT Guidance of the biopsy (77021).  If a fracture is proven, then a fracture treatment code could be used, and the closest would be 27235, and this could be an instance where the bone cement could be considered as "internal skeletal fixation."  The alternative would be to use the Unlisted Procedure, hip, 27299, and pair it with 23235.  If a "fracture" can't be proven with the help of the bone biopsy results, then you could go with the diagnosis of "femoral neck fracture" based on the clinical evidence as reported, and use the same codes.  If the bone biopsy reveals some other bone disease/disorder/diagnosis as a cause of the patient's chronic hip pain, then you would be better off to use the Unlisted Procedure, Hip, as above, but pairing it to another comparable procedure is tricky, and the Vertebroplasty code suggested could work.
     This is a very challenging case, and I would like to see what others have to say.  It hinges on the final diagnosis, proven or inferred.  I don't know if this procedure was done by an Interventional Radiologist or an Orthopedic Surgeon, which may or may not make any difference, but if done by an Orthopedic Surgeon, he may be able to help determine the most accurate/correct diagnosis to go with.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com


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