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Code This!

Scenario Week of January 26, 2010:
View Current Scenario

Inpatient Surgical Coding

The patient has a previous history of a right infected hip replacement with prosthesis removal and antibiotic spacer placement performed six weeks ago. She will be readmitted today for second stage removal of previously placed antibiotic spacer and revision of a total hip replacement. She has been on IV antibiotic therapy for the past six weeks.

Preoperative Diagnosis
Previously infected right hip prosthesis

Postoperative Diagnosis
Previously infected right hip prosthesis

Anesthesia: General

Estimated Blood Loss: Minimal

Complications: None

Operations Performed
1. Revision of a right total hip replacement
2. Removal of cement spacers

The patient was taken to the operating room, general anesthesia was administered, and she was placed in a left lateral decubitus position. The right hip was surgically scrubbed, prepped, and draped in the usual sterile fashion. The previous incision was accessed, at the tip of the trochanter, extending proximally and distally for approximately 8 to 10 cm. Blunt and sharp dissection was used to carry the incision down through the subcutaneous tissues until the underlying fascia was encountered. The fascia was divided longitudinally and a retractor was placed. Another incision was made at the tip of the trochanter and extended distally to the origin of the vastus lateralis muscle. An anterior flap of gluteus medius muscle and anterior hip capsule was identified and developed to the medial wall of the acetabulum. A capsulotomy was performed and excellent exposure was obtained. Scar tissue and any remaining cement were removed from the acetabular area, along with the previously placed cement antibiotic spacers. A size 56 Trilogy AB® Ceramic-on-Ceramic acetabular system was utilized and a single 25 mm superior screw was used to enhance fixation. A standard acetabular liner was placed and impacted. Integrity of the fixation was confirmed and the acetabular portion of the procedure was completed.

Attention was then turned to the femoral component, and the femoral canal was thoroughly irrigated with antibiotic solution. A size 16 fully porous-coated extended offset VerSys femoral stem was placed in the appropriate position of anteversion and was an excellent fit. The hip was then reduced one last time.

The wound was thoroughly irrigated with antibiotic solution, and a deep Hemovac drain was placed. The anterior capsule, vastus lateralis, gluteus medius, hip capsule, and fascia were closed with interrupted sutures of #1 Ethibond. The subcutaneous tissue and skin were closed with #0 and 2-0 Vicryl sutures and skin staples, respectively. Sterile dressings were applied, anesthesia reversed, and the patient was transported to the recovery room in stable condition.

Diagnosis Codes

736.39 Other acquired deformities of hip

Procedure Codes

00.70 Revision of hip replacement, both acetabular and femoral components
84.57 Removal of (cement) spacer
00.76 Hip bearing surface, ceramic-on-ceramic

Rationale for Diagnosis Codes
The AHA Coding Clinic for ICD-9-CM, 2nd quarter, 2008, provides guidance for the correct coding of a previously infected prosthesis with staged surgical treatment. For this scenario, the prosthesis has been removed, and the infection has resolved since the initial episode of care. The most appropriate code is 736.39 Other acquired deformities of hip, as the principal diagnosis. Since treatment is still ongoing, an aftercare code should not be assigned. Aftercare codes should only be assigned when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase.

Rationale for Procedure Codes
The principal procedure performed was a total hip revision. Code 00.70 was assigned since both femoral and acetabular components were revised. Coders should be aware that it is imperative to carefully review the operative report to obtain the correct location for each component revised. Conversion from a previously placed hip hemiarthroplasty to a total hip joint replacement should also be assigned to code 00.70. An instructional note in the ICD-9-CM text at code category 00.70 directs the coder to assign an additional code for any additional procedure such as removal of cement spacer and any type of bearing surface, if known. Code 84.57 Removal of cement spacer, should be assigned as a secondary procedure along with code 00.76 Hip bearing surface, ceramic-on-ceramic, since this specific material was specified in the operative report.

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