AR2728
Expert
Please Help! I am new to Ortho coding and in need of much asssitance on how to code the following note appropriately. Our Hospital is stating the only procedure to bill for is 20680-from what I have read on the forum this should be 27236 (previosuly failed closed reduction perc pinning performed 2 wks prior):
DIAGNOSIS:
1. Left hip femoral neck fracture, Previosuly failed closed reduction percutaneous pinning.
POSTOPERATIVE DIAGNOSIS:
1. Left hip femoral neck fracture, failed closed reduction percutaneous pinning.
PROCEDURE PERFORMED:
1. Left hip hemiarthroplasty.
2. Left hip hardware removal
This was done after an incision had been made in the skin. Once the cannulated
screws were removed, a standard posterolateral approach was taken to the hip. Skin was incised with a #15 blade. The gluteus fascia was incised. Once this was done, the gluteus maximus muscle was then split. Once this was done, the hip was slowly internally rotated. Trochanteric bursa was removed. The retractors were placed protecting the gluteus medius and minimus. The piriformis was then released from bone and tagged. Once this was done, the capsule was then T'd. The femoral head fracture was then identified and removed. This was then measured to be a size 47. At this point in time, the lollipop was placed in the acetabulum. Size 47 was the best fit. Once this was done, the femoral neck was identified. The femoral neck had broken very close to the shaft of the femur and just the edges were then cut to make it flat. No large femoral neck cut had to be made. Once this was done, the hip was then flexed and internally rotated. The cookie cutter was
then used. Once the cookie cutter was used, the canal finder was used followed by the entry reamer. The femur was broached until a size 15 was found to be stable. This would be a Zimmer press-fit femoral neck stem from the VerSys hip system. Once it was broached with a 15 and found to be acceptable, the femoral head and neck were then trialed. It was found to be suitable and the most stable having a +7 mm neck length and 28 mm femoral head diameter. Once the hip range of motion was trialed, the patient could flex her hip to 100 degrees, externally rotate to 60 degrees and internally rotate well past neutral without dislocating. The trials were then removed. The press-fit Zimmer size 15 femoral stem was placed with a 28 mm femoral head with a 7.0 mm neck length. A 28 mm liner was used and a 47 mm outer diameter shell. It should be noted that press-fit was
used for this patient. This was used for fear that cement would extrude through the prior screw holes that were made in the femur from the prior surgery. The patient went through range of motion again and there was no change. At this point in time, the wound was copiously irrigated with a pulsatile lavage. The capsule was then repaired using a 2.0 Orthocord. The external rotators were then repaired back to the greater trochanter with 2.0 Orthocord. Once this was done the gluteus maximus and its fascia were then closed with 0-Vicryl suture. Subcutaneous tissue was then closed with 2-0 Vicryl suture.
I was thinking 27236 and 20680....what about diag for 27236---the hospital is stating only 996.49 as primary diagnosis.
Please HELP ME!
DIAGNOSIS:
1. Left hip femoral neck fracture, Previosuly failed closed reduction percutaneous pinning.
POSTOPERATIVE DIAGNOSIS:
1. Left hip femoral neck fracture, failed closed reduction percutaneous pinning.
PROCEDURE PERFORMED:
1. Left hip hemiarthroplasty.
2. Left hip hardware removal
This was done after an incision had been made in the skin. Once the cannulated
screws were removed, a standard posterolateral approach was taken to the hip. Skin was incised with a #15 blade. The gluteus fascia was incised. Once this was done, the gluteus maximus muscle was then split. Once this was done, the hip was slowly internally rotated. Trochanteric bursa was removed. The retractors were placed protecting the gluteus medius and minimus. The piriformis was then released from bone and tagged. Once this was done, the capsule was then T'd. The femoral head fracture was then identified and removed. This was then measured to be a size 47. At this point in time, the lollipop was placed in the acetabulum. Size 47 was the best fit. Once this was done, the femoral neck was identified. The femoral neck had broken very close to the shaft of the femur and just the edges were then cut to make it flat. No large femoral neck cut had to be made. Once this was done, the hip was then flexed and internally rotated. The cookie cutter was
then used. Once the cookie cutter was used, the canal finder was used followed by the entry reamer. The femur was broached until a size 15 was found to be stable. This would be a Zimmer press-fit femoral neck stem from the VerSys hip system. Once it was broached with a 15 and found to be acceptable, the femoral head and neck were then trialed. It was found to be suitable and the most stable having a +7 mm neck length and 28 mm femoral head diameter. Once the hip range of motion was trialed, the patient could flex her hip to 100 degrees, externally rotate to 60 degrees and internally rotate well past neutral without dislocating. The trials were then removed. The press-fit Zimmer size 15 femoral stem was placed with a 28 mm femoral head with a 7.0 mm neck length. A 28 mm liner was used and a 47 mm outer diameter shell. It should be noted that press-fit was
used for this patient. This was used for fear that cement would extrude through the prior screw holes that were made in the femur from the prior surgery. The patient went through range of motion again and there was no change. At this point in time, the wound was copiously irrigated with a pulsatile lavage. The capsule was then repaired using a 2.0 Orthocord. The external rotators were then repaired back to the greater trochanter with 2.0 Orthocord. Once this was done the gluteus maximus and its fascia were then closed with 0-Vicryl suture. Subcutaneous tissue was then closed with 2-0 Vicryl suture.
I was thinking 27236 and 20680....what about diag for 27236---the hospital is stating only 996.49 as primary diagnosis.
Please HELP ME!