Orthopedic Coding Alert

Find out if you can report an osteotomy with a previous hip surgery conversion to total hip arthroplasty.

If you're puzzled by the hip surgery coding guidelines, let us help you get on the right track. We've gathered your top five hip coding questions and put our experts to the test. Review the following questions and answers to get the lowdown on everything from the Girdlestone procedure to resurfacing arthroplasty.

1. Look for THR, Osteotomy Rules

Question: Our surgeon performed a subtrochanteric osteotomy three years ago on a patient who suffered a slipped capital femoral epiphysis. Over the years, she developed degenerative joint disease of the hip and required total hip arthroplasty last month. This case was complicated by significant anatomic abnormalities from her previous osteotomy, as well as the presence of previously placed hardware. The surgical procedure included a repeat subtrochanteric osteotomy. Which codes should we bill for this?

Answer: You should report 27132 (Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft) for the patient's total hip replacement.

Can you report osteotomy? Although the Correct Coding Initiative (CCI) does not bundle 27165 (Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast) into 27132, insurers may not pay you for both procedures.

"I can't see that they are bundled, so technically both codes could be used, but it seems the primary procedure performed in this case is a conversion of a previous hip surgery to a total hip, and 27132 seems to cover that," says Denise Paige, CPC, coding and billing manager at Beach Orthopedic Associates in Long Beach, Calif.

"Prior to using those two codes, I would contact the carrier and ask if they would both be payable," Paige says.

If your insurer allows you to report both procedures, you should list your claim as follows:

• 27132
• 27165-51 (Multiple procedures).

"Another way to code this would be to use modifier 22 (Unusual procedural services) on 27132 for the extra work involved with the abnormalities encountered during surgery, along with an increased fee," Paige says.

2. Code the Girdlestone With Ease

Question: Our surgeon documented a Girdlestone surgery for hip osteoarthritis. Which code should we report?

Answer: During the Girdlestone procedure (also known as a resection arthroplasty or an excision arthroplasty), the surgeon removes the femoral head and neck, creating a resection arthroplasty, in which no true hip joint remains.

You should report code 27122 (Acetabuloplasty; resection, femoral head [e.g., Girdlestone procedure]) for this surgery.

3. Know Your Options for Hip Resurfacing

Question: Our surgeon documented a "Birmingham hip resurfacing surgery," in which he placed a metal cap over the patient's femoral head and inserted a metal cup into the pelvic socket. Which code should we report for this procedure?

Answer: CPT does not yet include a code for the hip resurfacing surgery (also referred to as "metal-on-metal resurfacing arthroplasty" or "metal-on-poly"). Some insurers have published policies for the procedure, while others are vague on their reporting guidelines.

For example, Cigna covers the procedure for treating aseptic necrosis of the head and neck of femur (733.42) and recommends that surgeons select from the following applicable CPT codes:

• 27125 -- Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)
• 27130 -- Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
• S2118 -- Metal-on-metal total hip resurfacing, including acetabular and femoral components
• 27299 -- Unlisted procedure, pelvis or hip joint

Your specific code choice will depend on the surgeon's documentation, but most coders and surgeons who must selec from the above list will probably choose 27130, assuming the acetabulum was also replaced.

"The current recommended coding for the resurfacing arthroplasty, as far as I'm aware, is as a total hip arthroplasty (27130)," says Brian S. Parsley, MD, assistant professor in the department of orthopaedic surgery at Baylor College of Medicine, and health policy and practice chair at the American Association of Hip and Knee Surgeons. "There has been discussion regarding a separate code, but this has not gone through."

Alternatively, the Regence Group refers coders to 27130 and the revision codes 27134-27138 for the procedure, although the payer also says that it considers the procedure investigational.

Look out for unlisted requests: Some insurers, such as BC/BS of North Carolina and BC/BS of Montana, advise practices to report 27299 (Unlisted procedure, pelvis or hip joint) for the service.

Other payers, including BC/BS of California and Healthlink, consider the procedure investigational and will not reimburse surgeons for it.

The bottom line: Ask your insurer which code you should report for the procedure. If the payer doesn't yet publish guidelines, ask your surgeon which of the above codes he thinks best describes his work.