Orthopedic Coding Alert

Pay attention to graft retrieval, resurfacing, and femoral block and check on carrier specifications.

In the last issue of Orthopedic Coding Alert, we looked at how to report additional procedures bundled in hip replacement code(s) that could complicate your code selection. This month, we'll continue reviewing hip replacement coding challenges by giving you advice on reporting grafts, femoral blocks, and resurfacing.

Next month: Look for instruction on coding infection and dislocation interventions with hip replacements and how to report the underlying cause.

Turn to Carrier Specifications for Bone Grafts

You report the partial or total hip replacement codes irrespective of whether your surgeon is using an allograft or autograft for the procedure. The hip replacement code descriptions include the terms 'autograft or allograft' or only 'allograft'.

According to CCI edits, you would report an autograft with 27125 (Hemiarthroplasty, hip, partial [eg, femoral stem prosthesis, bipolar arthroplasty]) only. There is no code for allograft for procedures other than the spine.  All other listed codes include both autograft and allograft in their description except for 27138 (Revision of total hip arthroplasty; femoral component only, with or without allograft), which only includes allograft in the code description," says Ruby O'Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist, Twin Cities Orthopedics, P.A. You need to carefully read and see which graft is inclusive in the code.

"Review of the CPT® description for CPT® codes 27132-27134 indicates that allograft and autograft are inclusive. The CPT® descriptions for CPT® codes 27125 and 27138 do not list the autograft as inclusive," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington. The missing autograft in the descriptor does not mean you do not report the graft. "This may confuse you to believe that the bone graft procedures should not be reported as additional code(s)."

The reporting of grafts is a multifaceted issue that depends upon carrier guidelines, care center guidelines, CCI edits, AAOS GSDG descriptions and CPT® descriptions of the codes," says Stumpf. "Allografts are included per AAOS GSDG description and the CPT® description for all of the CPT® codes for hip replacement".

1. Discern Graft Retrieval Method

Read carefully through the operative note to confirm how the graft was retrieved. If it is a locally harvested graft, say, for example, from the femoral head, you do not report any additional code(s) for bone grafts.

If your surgeon makes a separate incision at a distant site to obtain the graft tissue, you report 20900 (Bone graft, any donor area; minor or small [eg, dowel or button]) or 20902 (Bone graft, any donor area; major or large) in addition to the hip arthroplasty code.

Keep in mind: Code 27170 (Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area [includes obtaining bone graft]) is bundled with 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip arthroplasty], with or without autograft or allograft). "The code combination is bundled in CCI with an indicator of zero, no modifier allowed.  When performing 27130, the femoral head and neck are removed.  The intertrochanteric and subtrochanteric regions are left intact.  Since 27130 includes bone grafting, reporting 27170 would simply be considered creative coding," says O'Brochta-Woodward.

Again, check your carriers' preferences. "For Medicare and carriers following Medicare guidelines, CCI edits reflect that 27132 " 27138 include the autograft services. If the graft was harvested through a separate incision for CPT® code 27125, the graft can be separately reported," says Stumpf.

"AAOS, however, does not list autograft as inclusive in CPT® codes 27125, 27130, 27132, 27134 and 27138," Stumpf advises. "For private carriers that allow specialty guideline reporting, if the graft is harvested from a separate skin incision, per AAOS the graft may be separately reported. AAOS specifically allows separate reporting of an autograft with 27138 in the GSDG listing of allowed services" she adds. "For proper reporting of these services, it is imperative that the coder carefully review each set of guidelines, CCI edits, CPT® descriptions and understand which guidelines are being utilized by the carrier(s)."

Reminder: "CCI bundles both 20900 and 20902 into 27138 with an indicator of zero, meaning no modifier is allowed.  AAOS allows for harvesting of bone graft from a distant site for 27138," says O'Brochta-Woodward.

2. Do Not Bill Femoral Block

You won't report 64447 (Injection, anesthetic agent; femoral nerve, single) along with 27130, the reason being that a postoperative femoral block for managing pain is included in 27130.

Here's what the Correct Coding Initiative (CCI) manual states: "Postoperative pain management by the physician performing a surgical procedure is not separately reportable by that physician," says O'Brochta-Woodward. "Code 64447 is bundled into 27130 with an indicator of zero, no modifier allowed.  

If performed for post-operative pain control, per CCI, the injection is considered bundled."

"The coder should list the femoral nerve compression diagnosis on the claim as an additional diagnosis. A separate and distinct paragraph supporting increased complexity of the procedure, if any, is also recommended to aid in proper claim review," says Stumpf. "For additional reporting, there would need to be clear documentation of separate and distinct pathology requiring neurolysis supporting the medical necessity of the procedure."

Payer preferences: Don't forget to check for your carrier specifications. "If the carrier is following specialty guidelines, and the care center policy allows specialty guideline reporting for private carriers, CPT® code 64447 can be reported in some instances. AAOS guidelines do not include neurolysis in CPT® code 27130," says Stumpf.

3. Report the Resurfacing

Your surgeon may resurface the site with intent to remove a few centimeters of the bone around the femoral head to make it fit into the implant. One such resurfacing system is the 'BIRMINGHAM HIP Resurfacing System (BHR Hip)'. Read through the operative note to know if any resurfacing was done. You may look for mention of BHR Hip in the note. You will use the arthroplasty codes for these procedures, too.

How to code: "You report 27125 (hemiarthroplasty) if your orthopedic surgeon resurfaces only the acetabular surface or femoral head and 27130 (total hip replacement) if your surgeon does the resurfacing for both the acetabulum and femoral head," says Leslie A. Follebout, CPC, COSC, senior orthopedic coder & auditor, The Coding Network, Beverly Hills, California. "You may additionally include "Birmingham" in Box 19 to notify the payer of the type of implant used."

Bear in mind: "Per AAOS, hip resurfacing is reported with the standard CPT® codes. See http://www.aaos.org/news/bulletin/may07/managing9.asp," says Stumpf. "CPT® code 27130 is the correct code to use for every procedure that involves replacement of both hip joint surfaces (femoral and acetabular articular surfaces) with prosthetic implants, whether the implants are metal-on-polyethylene, metal-on-metal, ceramic-on-ceramic, or some other combination," she advises. "As noted previously, metal-on-metal bearing surfaces have been used for decades, and the bearing surface has no relationship to the selection of CPT® code. Whenever both joint surfaces are replaced with prosthetic implants, CPT® code 27130 should be used," she adds.

Reporting of resurfacing is partially driven by carrier policy. "AAOS states that a hip resurfacing is another method of performing an arthroplasty. If an acetabular component is placed, it would be reported the same as a total hip, 27130.  If no acetabular component, it would be reported as 27125, says O'Brochta-Woodward. "Some carriers are still asking that the procedure be billed using the unlisted code of 27299 (Unlisted procedure, pelvis or hip joint), while others are indicating to use the S2118 (Metal-on-metal total hip resurfacing, including acetabular and femoral components).  If there is no policy in place with the health plan, follow AAOS recommendation of 27125 or 27130."