Orthopedic Coding Alert

With more than a quarter of a million total hip replacements performed each year, coding for them should be a no-brainer, right?

Wrong. If youre automatically coding 27130 for a total hip replacement when you read those words on the operative report, you might be missing the fact that the procedure was actually a 27132 (conversion of previous hip surgery to total hip replacement, with or without autograft or allograft). Youre also missing out on the extra reimbursement to which your practice is ethically entitled.

This conversion code [27132] is a valuable code that is commonly overlooked, says Christine Banks, RRA, CPC, an orthopedic coding specialist at Massachusetts General Hospital in Boston, MA. It pays more than a total hip because, in a conversion, the surgeon has to remove old hardware from a previous hip surgerynot from a previous replacement. He or she must also deal with any scar tissue and then do the replacement.

Note: The term conversion is not synonymous with revision. Revision occurs when the previous procedure was a total hip replacement and some portion of that specific procedure needs to be redone and thus would be billed with one of the revision codes from range 27134 to 27138.

For example, the Massachusetts Medicare Fee Schedule allows $1,723.78 for a total hip replacement and $1,984.65 for a hip conversion.

Hence, an incorrectly coded total hip replacement for Medicare patient translates into about $261 in lost revenue per case. And it could be more for a non-Medicare patient, points out Barbara J. Cobuzzi, MBA, CPC, president of Cash Flow Solutions, Inc., in Lakewood, NJ.

She compares the relative value units (RVUs) of these two codes to underscore the importance of proper billing: Code 27130 has an RVU of 47.72, while a 27132 has an RVU of 55.11.

Dont Code Only From the Name of the Operation

Banks recalls how she learned this lesson the first time she encountered the conversion codeand almost missed it.

The operative report listed the name of the operation as left total hip replacement, which suggested 27130, she remembers.

But as she read further she discovered the actual procedure was really a conversion.

Note: When conducting an audit, Medicare auditors check the documentation to see what actually occurred during the encounter, rather than merely going by the name of the operation as listed on the operative report. So, to help coders accurately select CPT codes in generalas well as distinguish between a conversion and a total hip replacementalways scrutinize the entire contents of the operative report.

A conversion occurs when something happens to a previous hip surgeryperhaps a fractured acetabulum, degeneration, dislocation, or non-unionthus causing the need for a total hip replacement, explains Banks.

So one clue as to whether the case is a conversion or a total might be the listed diagnosis, such as post-traumatic osteoarthritis in Banks case. (See list of diagnostic codes specific to each procedure in the box on this page.)

Also, she suggests, watch for phrases in the operative report such as removal of deep hardware from left femur, Banks explains. This type of phrase tells you that the patient previously had some sort of hip surgery, she says.

Yet its the indications for a procedure that can help you pinpoint the right choice: The patient is a 36-year-old man who is brought into the operating room for elective left total hip replacement in treatment of an arthritic hip resulting from a comminuted fracture of his left acetabulum sustained one year ago.

This sentence indicates the procedure is not a total hip replacement, but potentially a conversion, Banks says.

Finally, check the description of the procedure to see what actually occurred. (Remember, in a total hip replacement and a hip conversion both the acetabular and femoral components are replaced in each procedure. But with the conversion, the surgeon removes internal fixation from previous surgery and excises scar tissue.)

For example, the operative note Banks provided contained these phrases:

The old scar was excised.

With careful dissection along the greater trochanter, two large fragment cancellous screws were identified and removed along with their washers.

Therefore, by coding 27132, plus HCPCS level II codes LT or RT to specify the left or right hip, Banks optimized reimbursement for her surgeons.

The diagnosis code she used was 716.15 (osteo-
arthrosis, localized primary, pelvic region and thigh).

But if the conversion was due to the loosening of the fixture, I would have first used the diagnostic code 996.4 (mechanical complication of internal orthopedic device, implant and graft) and then 716.15 as a secondary diagnosis, she adds.

Bundling Alert for Hip Conversions

Remember, with a conversion (27132), you cannot also bill for the following procedures because they are already calculated in the higher RVU of the conversion, according to the National Correct Coding Initiative (CCI):

20670: removal of implant, superficial, e.g., buried wired, pen, or rod;

20680: removal of implant, deep buried wire, pin, screw, metal band, nail or plate

27090: removal of hip prosthesis

27091: removal of hip prosthesis, complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer.

Note: These bundled codes should only be used when removal occurs without replacement.

The Complete Global Service Data for Orthopaedic Surgery, published by the American Academy of Orthopedic Surgeons (AAOS), also lists the following services as bundled with a conversion code:

27030, 27033, 27052, 27054: arthrotomy
Also, the AAOS lists these intraoperative services as not bundled with the conversion:

27000-27003: tenotomy adductors

13160, 13300, 14000-14350, 15000-15400, 15570-15776: complicated wound closure, or closure requiring local or distant flap coverage and/or skin graft, when appropriate

27165: inertrochanteric/subtrochanteric femoral osteotomy

20900 20902: harvesting and insertion of bone graft from distant site

Note: The CCI lists harvesting and insertion codes (20900 and 20902) as bundled. If you are billing Medicare, always use the CCI guidelines, Cobuzzi says. If you are not billing Medicare, check with the payer and then use which one is more favorable to your practice and what the doctor is comfortable with from a clinical point of view.

For example, the physician may decide to harvest the bone from a different site than the iliac crest and thus require a different incision. With the reason for decision documented, he or she would stand a good chance of appealing the bundling and being able to bill for it even with Medicare.

Remember, other than Medicare, there are no governmental mandates for payers on bundling; each payer has its own edits.