Orthopedic Coding Alert

Learn how 0054T-0056T can ease your CAD claims

When a patient presents for a follow-up visit after hip replacement surgery, you'll have to choose between three ICD-9 codes - V54.81, V67.09 or V43.64.

Orthopedic coders constantly face hip coding dilemmas such as this one, so we've compiled your most frequently asked questions and called our experts for advice. Read on to get the scoop on hip diagnosis and procedure coding.

Core Decompression Warrants Unlisted

Coders often wonder whether they're coding core decompression of the hip properly. Whereas some orthopedic practices report 20225 (Biopsy, bone, trocar or needle; deep [e.g., vertebral body, femur]) for this service, others report 26992 (Incision, bone cortex, pelvis and/or hip joint [e.g., osteomyelitis or bone abscess]), and still others report the unlisted-procedure code (27299).

Advice: In the January 2002 issue of CPT Assistant, the AMA, which oversees CPT code assignments, advised coders to report 27299 (Unlisted procedure, pelvis or hip joint) for core decompression. CPT Assistant states, "Code 26992 should not be reported, as this does not accurately describe the core decompression procedure."

Tip: Not only does the AMA advise against reporting 26992, but a general coding rule dictates that you should never select a code simply because it's "close" to what your surgeon performed. "Selecting a code that is 'close' is not compliant coding," says Marvel Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. "Knowingly and willingly coding a service or procedure with a code for the explicit motivation of bypassing denials and ensuring payment is fraud. The documentation will not support the procedure being billed."

You should send the insurer a copy of your surgeon's operative notes with your core decompression claim. To determine a price for the procedure, compare your surgeon's work to the work involved in the biopsy procedure that 20225 describes.

Report V54.81 Only for Recovering Patients

If your orthopedic surgeon examines a patient one year after her hip replacement and determines that she is in perfect health, which diagnosis code should you assign to the E/M claim? "This is probably the number-one hip diagnosis question that people ask me," says Randall Karpf, president of East Billing in East Hartford, Conn.

"When the new aftercare ICD-9 codes came out, people were very excited and started billing V54.81 (Aftercare following joint replacement) like crazy," Karpf says. "But you should only report V54.81 if the patient is still healing from the surgery."

Coding solution: If your asymptomatic patient presents to your practice for an annual visit following total hip replacement, you should report the appropriate E/M code (99211-99215 for established patients), along with V67.09 (Follow-up examination; following other surgery) and V43.64 (Organ or tissue replaced by other means; hip).

Use 0054T-0056T for CAD With Hip Revisions

Surgeons perform about 14,000 total hip revisions on Medicare patients every year, and many physicians have tried to optimize results by using computer-assisted devices (CAD) to assist them in planning and executing these difficult procedures. But coding - and collecting - for the CAD may prove difficult for orthopedic coders.

You should report a category III code for these new guidance devices, such as VectorVision and the OEC FluoroTrak.

In 2004, CPT introduced three new codes for computer-assisted musculoskeletal surgical navigational orthopedic procedures: