Orthopedic Coding Alert

Make sure these ICD-9 codes are on your list of common hip ailments

If your orthopedist is treating hip conditions, you need to know the pathology to properly assign diagnosis codes to prove medical necessity -- or you could be facing more than your fair share of denials.

The hip is one of the largest ball-and-socket joints and one of the most stable joints in the body, but over time it can be subject to wear-and-tear and injuries that can cause intense pain, says Leslie Follebout, CPC, coding department supervisor at Peninsula Orthopaedic Associates in Salisbury, Md. In addition, patients may suffer from hip injuries from falling or playing sports and require an orthopedist's intervention.

Remember Your ICD-9 Coding Rules

When your orthopedist meets with a patient, you should pay particular attention to her documentation of the patient's condition to assign the correct diagnosis codes, says Susan Vogelberger, CPC, CPC-H, CMBS, CCP, owner of Healthcare Consulting & Coding Education LLC in Boardman, Ohio.

For example, you would code an acute injury very differently from a chronic condition. According to ICD-9 guidelines, if your physician describes the same condition as both acute (or subacute) and chronic, and separate subentries exist in ICD-9's index at the same indentation level, you should code for both and sequence the acute (or subacute) first. The physician will determine the acute versus chronic diagnosis and should clearly document it in the patient's record, Vogelberger adds.

Be on the lookout: Terms you should watch for that indicate a chronic condition include the following:

- Degenerative

- History of

- Continued to recur

- Condition continues despite conservative management/measures

- Unresponsive to therapy

- Progressive

- Failure to improve

- Old.

For example: To show how acute versus chronic affects your code selection, you would choose 843.9 (Sprains and strains of hip and thigh; unspecified site of hip and thigh) for an acute hip sprain or strain and 718.95 (Unspecified derangement of joint; pelvic region and thigh) for a chronic condition, Vogelberger says.

Arthritis Can Support Several Treatment Options

Although rheumatoid arthritis (714.0) can affect the hip, most hip arthritis patients suffer from osteoarthritis (715.9x). These patients may have stiffness, pain, limited range of motion, and sometimes a complete inability to move the hip joint. Physicians use physical exams and x-rays to diagnose hip arthritis.

Surgeons usually prescribe conservative treatments, such as nonsteroidal anti-inflammatory drugs (NSAIDs), rest, physical therapy and occasionally injections, to initially alleviate the patient's symptoms.

When conservative treatments fail to address these symptoms, there are a number of surgical interventions that orthopedists can perform to repair damage done by hip arthritis, including hemiarthroplasty (27125, Hemiarthroplasty, hip, partial [e.g., femoral stem prosthesis, bipolar arthroplasty]), the Girdlestone procedure (27122, Acetabuloplasty; resection, femoral head [e.g., Girdlestone procedure]) or a total hip replacement (27130, Arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip arthroplasty], with or without autograft or allograft; or 27132, Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft).

Keep in mind, however, that your orthopedist will perform the Girdlestone procedure only rarely and then usually only for longstanding infection, says Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C

Avascular Necrosis Requires Surgery

Avascular necrosis (733.42) occurs when the bone at the femoral head loses blood supply (often due to a fracture or long-term steroid use) and portions of the bone tissue begin to die. This condition causes the bone to begin to collapse, resulting in severe pain and limitedrange of motion for the patient. Physicians usually diagnose this condition using x-rays, MRI and occasionally a bone biopsy (20240-20245).

In most cases, the physician will perform surgery to treat this condition, such as a core decompression (27299, Unlisted procedure, pelvis or hip joint), osteotomy (27165, Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast) or a total hip replacement (27130).

Dislocation Usually Means Trauma

A hip dislocation (835.00-835.13) is an extremely painful condition for which patients usually present to the emergency department. The condition is usually caused by trauma (such as a fall or a motorcycle accident) or following a total hip replacement (996.42 and V43.64).

Hip dislocations, caused when the hip's joint surfaces are separated, can be partial, complete, open, closed, anterior, posterior, recurrent or developmental, Vogelberger says. Physicians also refer to a partial dislocation as a subluxation, which indicates that the joint surfaces are only partly separated. For a complete dislocation, however, the joint surfaces have completely separated.

Look at surrounding structures: When a patient's hip dislocates, ligaments and muscles may be injured, Vogelberger says. And with a severe dislocation, -there is often injury to the blood vessels and nerves, as well as possible fractures.- If the dislocation is a result of trauma, you should be sure to use the E codes to supplement your primary diagnosis, she adds.

The physician will usually diagnose the condition based on physical exam and x-rays. Most of the time, the orthopedic surgeon can put the joint back into place using manipulation (27250-27252, Closed treatment of hip dislocation, traumatic; or 27256-27257, Treatment of spontaneous hip dislocation -).

In some cases, the physician will instead have to perform an open dislocation repair (27253-27254 or 27258-27259). If the surgeon treats a dislocation following total hip replacement, you-ll probably consider 27265-27266 (Closed treatment of post hip arthroplasty dislocation -) and 27134-27138 (Revision of total hip arthroplasty -).

Arthroscopy Is Common Labral Tear Treatment

Patients who suffer a labral tear of the hip have torn the labrum, which is the cartilage that surrounds the joint socket. The condition usually causes pain and a -catching- feeling in the hip. Physicians usually use a physical exam and MRI arthrogram to confirm a labral tear of the hip.

If conservative treatments such as rest, NSAIDs, physical therapy and corticosteroid injections do not alleviate the patient's symptoms, the surgeon may choose to perform surgery, such as an arthroscopic resection (29862, Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage [chondroplasty], abrasion arthroplasty, and/or resection of labrum) or arthroscopic repair (29999, Unlisted procedure, arthroscopy).

Careful with unlisted-procedure codes: Your orthopedist may perform the labral repair with an arthroscopic osteochondroplasty of the femoral neck and peripheral compartment, Follebout says. And he may also perform an acetabular rim trimming with the repair, which consists of distracting the hip join to debride and remove any osteophytes before the surgeon sutures the labrum back to the acetabulum.

-The arthroscopic hip labral repair is a very difficult procedure for the surgeon and requires advanced training,- she adds. -The office staff needs to be prudent to make sure the reimbursement for this procedure is adequate, especially since no code exists at this time and payment is left to the carrier's discretion.-

Trochanteric Bursitis Calls for Injections/Aspiration

Trochanteric bursitis, also called hip bursitis, is caused by inflammation of the bursa over the greater trochanter. This condition can cause pain, burning and swelling.

Not just for athletes: This condition commonly affects athletes but can also occur following hip replacement surgery or other procedures. Physicians usually prescribe rest and NSAIDs for this condition, followed by corticosteroid injections and possible aspiration (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) if the symptoms persist.

-If the pain is chronic and the patient has failed nonoperative treatment, the surgeon may suggest a bursectomy (27060-27062) with a tenotomy (27005-27006),- Follebout says. In addition, some orthopedists perform trochanteric bursectomy laparoscopically, and you would report this procedure with 29999.