Orthopedic Coding Alert

At $596 extra a pop, understanding ‘requiring anesthesia’ is worth the

Are you scratching your head when it comes to choosing a proper code from 27250-27254? The key may be highlighting specific factures such as anesthesia, trauma, and fracture. 

Here’s how to steer clear of these common pitfalls of traumatic hip dislocation coding.

27250/27252: Watch Anesthesia Requirements

Your first two coding options are 27250 (Closed treatment of hip dislocation, traumatic; without anesthesia) and 27252 (… requiring anesthesia).

Two requirements for these codes are fairly straightforward. Both codes are for (1) closed treatment and (2) traumatic dislocations.

Gray area: Coders often encounter trouble deciding whether the treatment qualifies as “requiring anesthesia” because of the different types, including local and general anesthesia and conscious sedation.

Different sources have different opinions on what anesthesia refers to in code descriptors. An August 2005 AAOS Bulletin article describing 26340 (Manipulation, finger joint, under anesthesia, each joint) states that “the terms ‘under anesthesia’ or ‘with anesthesia’ are now understood to reflect the appropriate anesthesia for a given patient and/or given situation,” rather than being limited to general anesthesia.

But CPT® Assistant (April 2005), referring to 23700 (Manipulation under anesthesia, shoulder joint, including application of fixation apparatus [dislocation excluded]), states that the “code descriptors, which include the phrase ‘requiring anesthesia’ or ‘under anesthesia,’ indicate that the work involved in that specific procedure requires the use of general anesthesia.” 

Watch out: “A lot of shoulder surgery is done now with regional blocks (usually inter-scalene block). Manipulation under anesthesia (MUA) is often done this way, so this gets to be a problem,” says Bill Mallon, MD, former medical director, Triangle Orthopedic Associates, Durham, N.C.

Safe bet: Report 27252 only if the surgeon uses general anesthesia, unless your payer tells you in writing that this code is appropriate for other forms of anesthesia, as well. Code 27252 has 16.68 more total relative value units than 27250 in the Medicare Physician Fee Schedule. Multiply 16.68 by the current 35.7547 conversion factor, and that translates to $596 more dollars. You don’t want to miss out on that when you deserve it — and you don’t want to have to pay it back for improper coding.

27253/27254: Catch Fracture, Ex Fix Blunders

Your next two options are open treatment codes for traumatic dislocations: 27253 (Open treatment of hip dislocation, traumatic, without internal fixation) and 27254 (Open treatment of hip dislocation, with acetabular wall and femoral head fracture, with or without internal or external fixation).

Again you should be able to narrow your options to these two codes easily by identifying two elements: open treatment and traumatic dislocation. But you need to be on your toes to distinguish dislocation alone (27253) from dislocation with fracture (27254).

Tip: Code 27254 describes an open reduction and internal fixation (ORIF), while 27253 specifically states no internal fixation (IF). A physician would only do an IF for a fraction, while FxFix could be for a dislocation only,” Mallon says. “You could identify the presence of ORIF done in the op note.” 

Fractures and dislocations are under the same section in the CPT® book and some physicians call these “fracture/dislocation” in their dictation. You may need to seek clarification from the physician for proper coding: “Is it a fracture, is it a dislocation, or both?”

Don’t miss: Both codes are appropriate for treatment without internal fixation, but 27254 states “with or without internal or external fixation.” Translation: You should not report a separate external fixation code with 27254. Although CPT® changed many descriptors to allow you to bill external fixation (20690, 20692) separately with several other codes, CPT® includes fixation in 27254.

If you try to report the two together, your system should kick out the fixation code. Correct Coding Initiative (CCI) edits bundle the external fixation codes into 27254.

835.XX: Follow These 5th Digit Clues

The ICD-9 manual groups your hip dislocation coding options into one handy group:

• 835.0X — Dislocation of hip; closed dislocation

• 835.1X — … open dislocation.

You will see closed dislocations more often than open, but your surgeon should document which it is. If not, be sure to verify before coding.

Your fifth digit options are as follows:

• 0 — … dislocation of hip, unspecified

• 1 — … posterior dislocation

• 2 — … obturator dislocation

• 3 — … other anterior dislocation.

Your surgeon should document whether the dislocation is posterior, obturator, or another anterior type. If you don’t have that information, ask for clarification.

Tip: Fifth digit “3” states “other anterior dislocation” because obturator dislocation is classified as an anterior dislocation, although it has distinct clinical indicators. The other anterior dislocations you may see (and use fifth digit “3” for) are iliac and pubic. But be prepared. The vast majority of dislocations are posterior, which may occur, for example, when the patient’s knee hits the dashboard during a head-on collision.

Watch out: You have other ICD-9 options for nontraumatic hip dislocations. See “2 More Tips Will Hone Your Hip Dislocation Skills” below for more information.

ICD-10: When your diagnosis system changes, you will look to the S73.0--- category for the “subluxation and dislocation of the hip.” You’ll have to choose your fifth digit based on whether the hip location is posterior, obturator, other anterior, central, or unspecified. Then you’ll have to go into further detail for the sixth digit, depending on whether the hip injury was a subluxation or dislocation and whether this affected the right or left hip. Finally, you’ll choose a seventh digit based on the episode of care. 

Modifier 57: Succeed With E/M + Treatment

You’ll see the majority of hip dislocations in the hospital or emergency department (ED), rather than in the office. If the ED doctor calls your surgeon to evaluate and treat the patient, you may report both an E/M and the treatment as long as the documentation reflects a separately identifiable E/M service. 

Don’t forget: You should append modifier 57 (Decision for surgery) to the E/M code.