# Periprosthetic fracture hip coding guestion



## peporter (Mar 16, 2009)

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

PROCEDURE
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
allograft.
3. Open treatment, left proximal femoral shaft fracture with internal
fixation.
4. Open removal of hip prosthesis, left hip.


DESCRIPTION OF PROCEDURE
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.


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## peporter (Mar 17, 2009)

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


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## mbort (Mar 17, 2009)

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


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## peporter (Mar 17, 2009)

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


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## hpatzke (May 14, 2010)

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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