# Fractured femur procedure code



## jdibble (Jul 27, 2015)

I am not sure which code to use and was hoping for some help with the following procedure:

PREOPERATIVE DIAGNOSIS:  Left proximal femur, periprosthetic femoral fracture.

POSTOPERATIVE DIAGNOSIS:  Left proximal femur, periprosthetic femoral fracture.

OPERATION:  Open reduction, internal fixation, left periprosthetic femur
fracture with salvage of prosthesis and bone graft.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operative theater, placed supine upon the operating room table.  After satisfactory general endotracheal anesthesia was administered, the patient was brought to the right lateral decubitus position with an axillary roll placed.  A time-out was carried out confirming the operative site with the operative consent, and the left lower extremity was then prepped and draped in the usual meticulous sterile fashion from the iliac crest to the ankle.  After meticulous sterile prepping and draping, a longitudinal incision was then made taking it through the previous lateral thigh incision from the tip of the trochanter distally about midway to the lateral thigh.  Sharp dissection was carried down to the tensor fascia lata, which was incised in line with the skin incision.  Proximally, the iliotibial band was noted to have been scarred down to the vastus lateralis and hip abductor tendon.  This was elevated and an Adson-Beckman retractor placed.  The lateral aspect of the femur was dissected down to by lifting the vastus lateralis muscle from the lateral aspect of the femur anteriorly.  This allowed for entering the fractured hematoma, which was evaluated and evacuated.  The fractured fragment proximally was noted to be displaced. The fractured hematoma was organized, was curetted and excised and removed with irrigation and suction. Evaluation of the femoral stem was then carried out.  The femoral stem was noted to be in stable position with the calcar.  The greater trochanteric fragment with the fragment that occupied about one-third to 40% of the circumference of the femur.  This was lifted inferiorly, laterally.  Two Dall-Miles cables were then passed about the distal third of the fragment.  This required dissection posteriorly where the previous surgeries had allowed for scarring of the tissues about the lesser trochanter.  The fragment was then reduced and held in anatomic position utilizing two Dall-Miles cables.  The crimps were positioned anteriorly to allow for placement of a lateral stabilizing plate.  A Biomet LCP plate was then contoured to the lateral femur.  This would allow for fixation proximally with 4.5 cortical screws and midway with additional cerclage wires and distally with bicortical screws and cerclage wires.  With the prosthesis now fixed and tightly so, it was now stable. The cabled fixation was then augmented with this lateral 12-hole plate. The plate was fixed proximally with bicortical screws through the greater trochanter and midway with two Dall-Miles cables and distally with two bicortical screws and one proximal 4.5 screw and an additional Dall-Miles cable. Throughout the case, C-arm fluoroscopy was utilized to evaluate the reduction and position of the plate and screw fixation.  The wound was then copiously irrigated with Bacitracin ointment, with Neomycin, normal saline and the fracture site was then bone grafted with cancellous bone graft, cancellous crouton decalcified bone graft.  Augmented by some local cancellous bone harvested from the femur.  This having been carried out satisfactorily, a deep vena vac drain was placed.  The deep tissues were closed utilizing #1 Vicryl with the edge of hamstrings and the undersurface of the vastus lateralis being closed. The vastus lateralis was fixed proximally, was then released with #0 Vicryl in interrupted fashion.  The subcu was closed with #0 Vicryl in a figure-of-eight fashion.  Subcu closed with #2-0 Vicryl in interrupted fashion, and the skin was reapproximated with skin staples.  The patient was returned to recovery after the wound was dressed with Xeroform, 4 x 4's and ABD pads. Estimated blood loss was 400 ml.  The patient was then taken to the recovery room and tolerated the procedure well without complications.

I am leaning towards 27244, 27170 but then I am not sure if it should be 27236 instead. Or if I should be using 27170 either!

Any help would be greatly appreciated!! 

Thanks,


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## caromissunc1 (Jul 30, 2015)

Greetings and Salutations!  I would use 27244 as well.  However, 27170 is bundled with 27244.  If the autograft was obtained through the same incision, you probably won't be able to code it separately.  If the autograft was obtained through a separate incision or separate site, you can use either a 59 modifier or an XS, depending on insurance.  Good luck!


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## jdibble (Jul 31, 2015)

caromissunc1 said:


> Greetings and Salutations!  I would use 27244 as well.  However, 27170 is bundled with 27244.  If the autograft was obtained through the same incision, you probably won't be able to code it separately.  If the autograft was obtained through a separate incision or separate site, you can use either a 59 modifier or an XS, depending on insurance.  Good luck!



Thank you very much for your answer! You were very helpful!!


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