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Scenario Week of September 13, 2010:
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Indications for Procedure
Patient is an 88-year-old female who sustained a right intertrochanteric hip fracture after a fall. She has been taken to the operating room for an open reduction and internal fixation of this right hip fracture. Consent has been signed and can be found in the chart. Risks include death, infection, nerve or blood vessel injury, bleeding, need for blood transfusion, blood clots, failure to heal, and the need for further surgery.

Approach and Surgical Procedure
The patient was administered 1 gram of Ancef via IV in the holding area. She was then taken to the operating room where a spinal anesthetic was placed by the anesthesia service on the hospital bed. She was transferred over to the fracture table in the supine position where a well-padded post was positioned. The left lower extremity with a thigh-high TED stocking was placed into the thigh/leg support with foam padding over all bony prominences. The left lower extremity had abundant padding placed around the foot and ankle region and was then placed in the foot and ankle support. Next, the right hip was visualized under AP and lateral fluoroscopic views. The femoral head and neck were well-visualized in both planes at this time.

Next, the right hip was prepped and draped in the usual sterile fashion utilizing Betadine prep followed by toweling out and holding the towels with staples, followed by drying, followed by placement of a shower curtain. Next, a guidepin was placed over the hip and an AP fluoroscopic view taken. Next, the proposed skin incision of approximately 12-cm in length was marked on the skin. The skin incision was then made with a #10 blade, going down through the skin and subcutaneous tissue. Hemostasis was achieved with electrocautery. The IT-band was split longitudinally with electrocautery.


Next, the vastus lateralis was elevated and the posterior one-third was split longitudinally with electrocautery, also with use of a Key elevator, followed by placement of a Bennett leg loose retractor. The vastus lateralis was further developed with electrocautery at this time to expose the lateral femoral shaft. Next, the 135-degree guide with the pin was placed on the lateral femoral shaft and the guidepin was advanced through the lateral cortex into the femoral neck and checked under the lateral view, found to be in good position, and advanced into the head region, again checked under AP view, and then advanced into subchondral bone, again checked on the lateral view, and found to be in good position. This was then measured. It measured 90-mm. We therefore decided to triple ream to 80-mm and place an 80-mm hip screw. Triple reaming was performed under AP fluoroscopic guidance. Next, the 80-mm hip screw was placed, again under fluoroscopic guidance, and once felt to be in the correct position, it was checked again under the lateral view and found to be within the femoral head nicely. Back to the AP view, it was again visualized. The fracture was well reduced. The screw was in good position. The four-hole, 135-degree plate was advanced over the connector onto the screw and gently seated against the lateral femoral cortex. The connectors and guidepin were then removed. The plate was gently impacted with a plastic impactor and mallet. Once fully seated, it was manually held in this position. The most distal hole in the plate was filled by drilling through both cortices, followed by depth gauge tapping, and placement of a propylene fully-threaded 4.5 cortical screw. The remainder of the holes in the plate were filled in a similar manner by drilling through both cortices, followed by depth gauge, and placement of the appropriate length 4.5, fully-threaded self-tapping screws. All screws were again securely tightened. The locking nut/screw was placed into the hip screw portion and was fully tightened. The entire contents were again checked under AP and lateral fluoroscopic views with hard copies printed off the C-arm.

Everything looked nicely reduced and all hardware was in good position. The site was again copiously irrigated with normal saline solution. The IT-band was closed with 0-Vicryl figure-of-eight interrupted sutures. The subcutaneous tissue was again irrigated with normal saline solution and the subcutaneous tissue was closed with 2-0 Vicryl interrupted sutures and the skin was closed with staples, followed by placement of Adaptic, 4x4s, ABD dressing, and elastic tape. The patient was then gently transferred back to the hospital bed and transferred to recovery without difficulty.

Please assign the correct CPT and ICD-9-CM codes for the procedure above.

CPT Answers
Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage

Although this is noted as a "hip fracture", the intertrochanteric area is actually a section of the femur, just below the femoral head. This is the most common type of hip fracture. There are different codes available for treatment of these fractures, based on the type of treatment performed. In this case, we have an open treatment, with a plate and screw being placed, which is best coded using 27244. Modifier RT can give the payer additional information about which side is involved in the procedure.

ICD-9-CM Answers
        Closed fracture of intertrochanteric section of femur

In the case of this patient, there are no other mentioned diagnoses outside of her current injury. Her current injury, as described above, is a comminuted fracture. Comminuted fractures are closed fractures, so we are looking specifically in ICD-9-CM for a closed fracture of the intertrochanteric section of the femur.

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