Orthopedic Coding Alert

When your surgeon decides a patient needs a hip replacement, coders need to be ready to spring into action with knowledge of the different types of replacements they might perform.

Knowing what terms to look for and what conditions patients who need hip replacements suffer from is a good place to start. It’s also not a bad idea to brush up on the documentation basics you should include on your claim.

Read on for some expert insight on coding hip replacement surgeries.

Partial Replacement Typically Involves Femoral Head

The first thing you’ll want to deduce on the claim is whether the surgeon performed partial or total hip replacement. There are different codes for each, confirms Megan Szczepanski, CPC, COSC, professional coding specialist III at West Virginia University Medicine in Morgantown.

“A partial hip replacement is when they only work on and replace the femoral head for degenerative reasons: for example, osteoarthritis. In the encounter notes, the surgery could be called a hemiarthroplasty or bipolar arthroplasty, she says.

Report partial hip replacements with 27125 (Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)). “CPT^® code 27125 is also usually chosen for planned partial hip replacements

not due to a fracture,” confirms Denise Paige, CPC, COSC, coder with PIH Health Physicians.

Caveat: Make sure that the work on the femoral head actually qualifies for 27125, Szczepanski warns.

If the reason for the femoral replacement is a femoral neck fracture, then you would code 27236 (Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement) instead. If you have any questions about reporting 27236 or 27125, check with your payer before coding the service.

Total Hip Replacement Could Be Conversion Surgery

There are also a pair of codes for total hip replacement; which one you report will depend on the patient’s presurgical status.

If the surgeon replaces both the femoral component and acetabulum, you’d report 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft).

There is also another code for total hip replacements you’ll want to consider in certain situations. “If the patient had a prior hip surgery — for example, prior ORIF [open reduction and internal fixation] of femoral neck, hip dysplasia surgery, hemiarthroplasty — and are now undergoing a total hip arthroplasty, you would choose 27132 [Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft] instead of 27130,” explains Szczepanski.

Use Keyword Smarts to Discern Replacement Type

Knowing the key terms the surgeon might use in the notes will help you greatly as you try to choose the correct hip replacement code. “The provider should indicate clearly which components were replaced. For a total hip both femoral and acetabular components are replaced, in a hemiarthroplasty only one,” explains Paige.

But if the provider does not indicate clearly which type of hip replacement they performed, the coder might have to have deeper knowledge.

“In the op note the surgeon will generally list the components that they implanted. If the only components placed are femoral head and stem, you have a partial [replacement],” says Szczepanski. “If they dislocate the hip, clean up osteophytes off of the labrum or acetabulum but do not add a cup and then they remove the femur and replace it, then you also have a partial.”

“The mechanism of the condition is a clue; is it for a degenerative problem or a fracture?” asks Paige. “The term ‘hemiarthroplasty’ can lead you to code 27236 or 27125, but the reason for the surgery would help you chose the correct code.”

If you see that they reamed and shaped the acetabulum and inserted a cup/shell along with removing the proximal femur and replacing that with a stem and head, then you have a total hip replacement. “My surgeons generally specify in the name of the procedure part of their op note which [operation] they are doing,” Szczepanski says.

Look for These ICD-10 Codes on Hip Replacements

According to the Centers for Medicare & Medicaid Services (CMS), there are well over 1,000 ICD-10 codes that could prove medical necessity for hip replacements. Here’s a sampling of the codes, from the Medicare Coverage Database article A57765: Billing and Coding: Major Joint Replacement (Hip and Knee):

• C47.21 (Malignant neoplasm of peripheral nerves of right lower limb, including hip)
• D21.22 (Benign neoplasm of connective and other soft tissue of left lower limb, including hip)
• M05.451 (Rheumatoid myopathy with rheumatoid arthritis of right hip)
• M06.051 (Rheumatoid arthritis without rheumatoid factor, right hip)
• M07.651 (Enteropathic arthropathies, right hip)
• M13.151 (Monoarthritis, not elsewhere classified, right hip)
• M16.11 (Unilateral primary osteoarthritis, right hip)
• M24.652 (Ankylosis, left hip)
• M25.252 (Flail joint, left hip)
• M84.359S (Stress fracture, hip, unspecified, sequela)
• S72.141X (Displaced intertrochanteric fracture of right femur)
• T84.020A (Dislocation of internal right hip prosthesis, initial encounter)
• Z89.621 (Acquired absence of right hip joint)

Note: This is merely a list of ICD-10 codes CMS might accept for your hip replacement claims — not a guarantee of payment for hip replacement surgery. Always code to the notes and choose the best codes based on the documentation on hand.

Include Evidence of Prior Tx

According to Paige, if your provider attempted any more conservative treatments before opting for hip replacement, it can’t hurt to include it in the notes. “Anytime a joint is replaced due to a degenerative condition it’s a good idea for the operating surgeon to indicate in his op note any more conservative treatments — injections, PT [physical therapy], etc. — or previous conditions.”

Szczepanski says that the type/amount of documentation required for a hip replacement claim could be payer dependent.

“Different [payers] have different rules,” she says. For example, the payer might want to see conservative treatment for three months and chronic, severe, disabling pain for at least six months, along with of factors.

Remember: “The patient would likely need to be preauthorized for these surgeries by their insurances. Whether they meet the qualifications for meeting their insurance standards for paying, should be reviewed at that time,” explains Szczepanski.