Anesthesia Coding Alert

Question: The anesthesia record documents a fractured hip with an ORIF (open reduction internal fixation) hip procedure. We usually report 01230, but 01210 seems more appropriate. The surgeon's report is unavailable, so which code should we choose?

Answer: If you crosswalk 27236 (Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement), your first option is 01230 (Anesthesia for open procedures involving upper two-thirds of femur; not otherwise specified). As every anesthesia coder knows, however, the first Crosswalk option isn't always the best.

Check documentation: You're correct in saying the Crosswalk's alternative code 01210 (Anesthesia for open procedures involving hip joint; not otherwise specified) better describes this case -- maybe. If you don't have the operative report or physician documentation specifying the upper two-thirds of the femur, 01210 is a better choice because it states, "not otherwise specified." Submit 01210 with the documentation explaining the procedure and why you selected 01210 rather than 01230.