# 27125 vs 27236 - Hey fellow coders



## Desperate Denise (Mar 22, 2010)

Hey fellow coders - this one is killing me.  I cannot decide whether to use 27125 or 27236?

Can someone please please help me code this one?  I am not sure if I can bill for the ORIF of the greater trochanter or the hardware removal?   This is a tough one - I do not want to use 27125 if it is not appropriate.

Thank you in advance for your help!!!!       

PREOPERATIVE DIAGNOSIS:  Right subtrochanteric fracture nonunion with
cephalomedullary screw cutout.

POSTOPERATIVE DIAGNOSIS:  Right subtrochanteric fracture nonunion with
cephalomedullary screw cutout.

PROCEDURE PERFORMED:  Right hip:
1.  Removal of hardware, deep, including all components of a
previously inserted gamma nail.
2.  Application of and insertion of a calcar replacing
hemiarthroplasty.
3.  Application and open reduction-internal fixation of greater
trochanter using trochanteric cable plate.

COMPONENTS USED:
1.  A size 7 Omnifit calcar replacing cemented stem with stem length
of 150 mm and body size of 35 mm.
2.  An 11 mm distal spacer.
3.  A 47 x 26 mm bipolar component head.
4.  A 26+0 C taper fit head.  
5.  A 150 mm length Dall-Miles trochanter grip plate. 

OPERATIVE INDICATIONS:  The patient is a 91-year-old female with a
history of subtrochanteric fracture sustained in September 2009.  She
underwent cephalomedullary nailing at that point with evident screw
cutout and varus deformation of the subtrochanteric fracture over the
preceding 5 months.  She presented to the office with cephalomedullary
screw cutout.  At this point, the risks and benefits of her revision
nonunion into a calcar replacing cemented hemiarthroplasty were
discussed with the patient, with risks which included bleeding,
infection, blood clot, risk of anesthesia, stiffness, operative
failure, risk of needing further operations and her having continued
pain.  The patient understood those risks and wished to proceed with
the procedure.

DESCRIPTION OF OPERATIVE PROCEDURE:  The patient was met in the
preoperative area.  Her right hip was signed after obtaining medical
clearance and cardiology clearance.  She was brought to the operating
room.  She underwent general anesthesia and was placed on the
operating room table. She was placed in the left lateral decubitus. 
She was given 1 gram of IV Kefzol.  Her right leg was prepped and
draped in standard sterile fashion.  A time-out was performed,
identifying the right hip as the correct hip.  The first part of the
operation was performed by taking out the 2 distal interlocking screws
within the gamma nail.  This was done through 2 small incisions
through previous incisions.  The screws were found percutaneously and
taken out via the gamma nail screwdriver.  Attention was then turned
to the hip joint itself.  Using an incision starting at her mid-thigh,
incision extending proximally and posteriorly, a skin incision was
made.  The soft tissues were dissected down to the level of the tensor
fascia lata.  Tensor fascia lata was identified.  Hemostasis was
achieved using electrocautery.  Incision following the line of skin
incision was made into the fascia and the greater trochanteric bursa
was taken down.  The piriformis was identified and taken sharply off
the femur.  The remainder of the external rotators were taken down. 
Capsule was identified and a trapezoidal-shaped capsulotomy was made
and tagged for future repair.  Care was used to protect the sciatic
nerve at all times.  Once this was performed, the hip was dislocated. 
Attention was then turned to removal of the gamma nail.  The gamma
nail was sequentially removed starting with the set screw, which was
removed using set screw screwdriver, which was through the top of the
nail, which was easily palpable through the tip of the trochanter. 
The cephalomedullary screw was found and then taken out appropriately,
followed by the nail extraction device, which was applied to the gamma
nail and then the gamma nail itself was removed.  Attention was then
turned to the proximal femur.  A very low neck cut at the area of the
nonunion was identified and the neck cut was made in line with the
calcar plane.  The femur was then sequentially prepared.  During
preparation, it was noted that the greater trochanter was also under
nonunion and it was decided that this would eventually need further
fixation with probable trochanteric grip plate.  The proximal femur
was then reamed to a size 7 and broaching to a size 7 with an
appropriate anteversion.  Once the femur was in appropriate
anteversion, trials were placed with a 35 mm body with a +0 head and
47 mm cup.  The cup was sized in a ball and stick fashion and found to
have good fit and fill.  Once the trial reduction components were
placed, range of motion was tested.  The thigh was flexed up to 120
degrees without instability.  At 90 degrees of flexion, the patient
was able to internally rotate to 70 degrees.  Position of sleep was
stable.  The patient was stable anteriorly.  Leg lengths appeared
appropriate to preoperative x-rays.  An intraoperative x-ray was taken
to confirm this leg length.  

At this point, all trial components were removed.  The femur was pulse
lavaged and a distal cement restrictor was placed.  A size 11 cement
centralizer was placed onto a size 7 Omnifit calcar replacing stem
with 35 mm body, which was opened and cemented into place.  All
extraneous cement was removed.  The hip was re-trialed again with
trial head and bipolar cups and found to have excellent reduction. 
Trial components were then removed and a +0 head with C taper and a 47
mm outer diameter bipolar cup was impacted in good position and found
to have good purchase.  The hip was reduced.  After thorough
irrigation, the hip capsule was closed.  

Attention was then turned to the greater trochanter, which still
appeared loose and freely mobile.  It was determined to use a
trochanteric grip plate.  A 150 mm trochanteric grip plate with 2
cables was opened and additional 3 more cables were placed, with 1
cable being outside of the plate, cerclaging the femur distally as a
third gripping plate.  The cable plate sat nicely.  After thorough
irrigation, intraoperative x-rays were checked to check the reduction
as well as to ensure no intraoperative fractures were performed.  This
appeared intact and reduction appeared intact.  After hip capsule
closure, the tensor fascia lata was closed using interrupted #1
Vicryl.  The subcutaneous tissues were closed using 2-0 Vicryl.  The
skin was closed using staples.  On the distal 2 incisions near the
thigh, the subcutaneous tissues were closed using 2-0 Vicryl and skin
was closed using staples.  Dry sterile dressing with Xeroform was
applied.  The patient was placed in hip spica wrap.  She was extubated
and taken to the PACU as per normal postoperative routine.


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## bakert (Mar 23, 2010)

Per a prior posting I found months ago AMA and AAPC decided that if the ORIF/Hemiarthroplasty is for the repair of a fracture then use 27236. If the Hemiarthroplasty is not for a fracture then use 27125. I hope this helps.


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## Desperate Denise (Mar 24, 2010)

*Bakert*

Thank you!

I had read that but the doc seems to think that he can use 27125 along with the ORIF of the greater trochanter - oh boy.

Have a great day!!

Denise


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