Orthopedic Coding Alert

These key terms make coding for hip procedures easier and more accurate.

Guest Columnist: Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P

If you think your hip is that thing jutting out at you in the mirror, your nomenclature needs a rehaul to ensure youre nailing the correct codes. Coding for hip fractures and other procedures is easier when the coder is hip to the anatomy and terminology.

Common mistake: The average person refers to the prominent part of the pelvis that juts out just below the waistline (the iliac crest) as the hip. However, the hip portion of the pelvis is really about five inches below and is called the acetabulum, or true hip.

The ABCs of Hip Anatomy

Hip joint: Three areas of the pelvic structure form the acetabulum or the socket: the ilium, the ischium, and the pubis.

Femoral head: This is the ball, which is located in the upper end of the femur. The femoral head and the acetabulum are covered with a layer of cartilage that provides shock absorption and load distribution within the hip.

Femoral neck: The area below the femoral head where the bone narrows into a tubelike structure about two inches long.

Greater and lesser trochanters: These are part of the femur located just distal to the femoral neck where the bone widens into two large prominences. Intertrochanteric refers to any region between the two trachanters and subtrochanteric refers to the widened part of the shaft just below the lesser trochanteric.

Bigelow ligament (anterior iliofemoral ligament): This ligament covers the femoral neck and the ligament teres, which is the round ligament between the middle of the femoral head and the center of the acetabulum.

Adductor muscles: This group of five muscles pulls the thigh inward. They include the adductor magnus, adductor longus, adductor brevis, pectineus, and the gracilis muscles.

Internal and external rotators muscles: These include the obturator gemelli, quadratus femoris, the piriformis, the gluteus maximus, gluteus medius, gluteus minimus, iliopsoas,rectus femoris, satrius, and the tensor fascia lata muscle.

Arteries: These include the femoral artery, inferior gluteal artery, obturator artery, and the superior gluteal artery.

Nerves: Three large nerves pass near the hip. They are the femoral nerve, the obturator nerve and the sciatic nerve.

Code Treatment Type, not Fracture Type

When coding for hip fracture repair, make sure that you understand the three different repair methods: closed, open, and percutaneous. Per CPT, fracture care is described by the type of treatment rendered --not by the fracture type. The repair methods are defined as follows:

Closed treatment: The fracture site is not surgically opened and can be performed with or without manipulation, or with or without skeletal or skin traction.

Open treatment: Refers to the requirement for a surgical incision to expose the fracture for direct visualization or opened remotely to insert an intramedullary nail across the fracture site. Internal and/or external fixation may be applied.

Percutaneous: (Latin per, through, + cutis, skin):

Treatment is affected through the skin. Treatment is neither open nor closed. Some fractures can be set percutaneously.

The physician performs percutaneous skeletal fixation through a small stab incision, usually with the aid of fluoroscopy.

Test Your Terminology

Its important for coders to recognize common terms and eponyms. Not all op notes are created equal -- what one doctor reports as a femoral head-neck junction fracture may be simply referred to as a subcapital by another. Familiarize yourself with the following:

Basal neck: Fracture of the base of the femoral neck at the junction of the trochanteric region

Dashboard: Fracture of the posterior lip of the acetabulum chips when the femoral head is driven against it

Extracapsular: Fracture located outside the joint capsule

Femoral neck: Transcervical fracture through the mid portion of the femoral neck

Intertrochanteric: Fracture along a line joining the greater and lesser trochanters

Mallory: Femoral shaft fractures occurring during total hip replacement

Pauwels classification: Refers to the angle the fracture makes with the horizontal

Pertrochanteric: Fracture involving the proximal femur where the fracture line passes through both the lesser and greater trochanters

Pipkin: Based on the location of the fracture head and neck when associated with a posterior hip dislocation

Subcapital: Femoral fracture at the head-neck junction

Subtrochanteric: Transverse fracture of the femur just below the lesser trochanteric.

Up Your Hip Claim Pay With 4 Overlooked Sources

This speed tool solves your modifier 22 (Increased procedural services) reservations without landing claims in hot water. Dont let hunting for hip codings two mustknow facts stop you from including allowed moneyboosting items on your claim.

Take 2 Steps to Land the Correct CPT Code

Step 1: Choosing the correct CPT code for hip repair fractures depends on the type of treatment rendered -- closed, open, or percutaneous.

Step 2: Once that is determined, you will need to decide whether the fracture required manipulation, internal fixation, or prosthetic replacement.

Dont unbundle procedures you read about that are actually included in the procedure. Some you might spot are: Manipulation refers to reduction or restoration of a fracture or joint dislocation to its normal position by manually applying force and is not separately reportable.

You should use codes for obtaining autografts through separate incisions only when the graft is not listed as part of the main procedure. The same principle applies to coding the external fixation application.

Ask 4 Questions before Using Modifier 22

Often a total hip arthroplasty performed on a patient with a congenital or developmental hip dislocation warrants the use of modifier 22 due to the more advanced techniques for reconstruction. Before using modifier 22 with orthopedic codes, be sure your physician has clearly documented the extra work involved.

Tool: Ask yourself the following four questions to check for documentation before using modifier 22:

1) Did the procedure last unusually long? If so, how long and what was the reason?

2) Did the patient have an unusual anatomic variant or unexpected finding that complicated the procedure?

3) Was the extent of the procedure greater than expected?

4) Were there additional resources required to complete the procedure?

Note: Include the operative report and a letter explaining why the procedure was more complicated than the normal hip arthroplasty.

Dont Miss Out on Revenue From Debridement

If an open fracture wound is contaminated with foreign material that requires prolonged cleansing and debridement of tissue, you can report the debridement codes in addition to an open fracture code. To ensure the correct code choice, note the type of tissue the physician debrides using this chart:

" 11010 -- Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues

" 11011 -- & skin, subcutaneous tissue, muscle fascia, and muscle

" 11012 -- & skin, subcutaneous tissue, muscle fascia, muscle, and bone.

More Revenue! Code for Supplies and Materials

If the physician provides supplies and materials over and above those that are usually included in the procedure, you can report these separately. Some examples of items include sterile trays, supplies, materials, and drugs. They can be reported with the generic supply code 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]), or with HCPCS Level II codes.

Keep in mind: The global surgical package includes the initial placement and removal of casting and/or strapping. The surgical package, however, does not include subsequent replacement, which you can be bill separately when performed.

Guest Author Bio:

Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, has more than 18 years of experience in healthcare coding and reimbursement. She is the CEO and owner of Healthcare Consulting & Coding Education, LLC, located in northeast Ohio, which provides auditing,consulting, and educational services to facilities, physician offices, hospitals, and accounting firms. Susan has performed numerous audits reviewing hundreds of medical records for documentation, medical necessity, and correct coding. She also specializes in compliance and is knowledgeable and proficient in all areas of coding, reimbursement, and government regulation. Susan has authored numerous articles that have been published in leading coding and billing magazines and is a certified Professional Medical Coding Curriculum (PMCC) instructor and presenter of workshops and seminars.