Orthopedic Coding Alert

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

If you’re scratching your head when it comes to hip surgery coding guidelines, then you’re not alone. 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. Prior to using those two codes, experts recommend that you contact the carrier and ask if they would both be payable.

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

• 27132
• 27165-51 (Multiple procedures).

Note: If the medical necessity for the osteotomy was established (i.e., some type of rotational deformity), then you should report 27165, provided your physician uses internal fixation.

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

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 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.

Note: CPT^® advises that you would only report the hemiarthroplasty code (27125) only if your physician resurfaces one side. Additionally, CPT® advises reporting one code (27130) for a resurfacing hip arthroplasty when both the femoral head and acetabulum are resurfaced. See CPT® Assistant Dec 2011.

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

Alternatively, you might look to 27130 and the revision codes 27134-27138 for the procedure, although some payers will consider the procedure investigational.

Look out for unlisted requests: Some insurers advise practices to report 27299 (Unlisted procedure, pelvis or hip joint) for the service. Other payers 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.