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Code This!

Scenario Week of October 02, 2014:
View Current Scenario

Assign the correct 2014 CPT and ICD-9-CM diagnosis codes for the following outpatient coding scenario.

Preoperative Diagnosis

  1. Left hip open wound
  2. Left hip recurrent dislocation of the hip prosthesis

Postoperative Diagnosis

  1. Left hip open wound
  2. Left hip recurrent dislocation of the hip prosthesis

Procedures Performed

  1. Left hip debridement of skin, subcutaneous tissue, and fascia
  2. Left hip revision of arthroplasty with exchange of the femoral head and acetabular liner to a constrained system

Implants

  1. DePuy Pinnacle GVT constrained +4 neutral 32 mm inner diameter 40, 54 outer diameter acetabular polyethylene
  2. +S DePuy Articul/eze femoral head

Indication for Surgery: The patient is an 80-year-old female who underwent a total hip replacement for a malunion with vascular necrosis of the head after intramedullary nailing for a hip fracture. Her postoperative course was complicated by a wound infection with coliform bacteria. This infection was debrided superficially, and a wound VAC was placed. At that procedure, she was noted to have a hip dislocation as well which was close reduced. In the subsequent two weeks, she dislocated the hip an additional three times and based on these recurrent dislocations, the decision was made to proceed with revision of her hip replacement with debridement of the wound to minimize postoperative infection risk.

Description of Surgery: On the day of the procedure, the patient presented to the preoperative area where she was evaluated by Anesthesia. Her site was marked, all final questions were answered, and informed consent was signed and placed in the chart. The patient was transported to the operating suite and moved onto the OR table in the supine position. IV antibiotics were administered. Surgical time-out was performed and general anesthesia was induced. The patient was moved in the right lateral decubitus position using pelvic stabilizers on the ASIS and sacrum. The wound VAC was removed and the left lower extremity was prepped and draped in a standard sterile fashion.

The wound was debrided in a full-thickness manner. Approximately 4 mm were resected circumferentially around the incision at the level of the skin. This was carried out down through the subcutaneous layer to leave the entire envelope where the wound VAC had been creating granular tissue intact. Once the entire area was ellipsed out, it was resected in toto and discarded. The hip instruments were on a clean table and these were used for the next portion of the case.

The left lower extremity was then re-prepped and draped. The Tegaderm and lap sponge were removed after the hip had been provisionally draped out. The extremity was prepped using DuraPrep and standard sterile precautions were maintained. The gluteus was split in line with its fibers and the dissection was carried down deep using electrocautery dissection. There was a cavitary defect where the hip had been dislocated, but I did not encounter any frank infection. There were no malodorous aromas. The hip was frankly dislocated as expected. The femoral head was removed using a bone tamp and the acetabulum was exposed. Deep debridement with a rongeur was completed to remove some fibrinous tissue. The polyethylene was then removed using a sharp osteotome and disengaged from the acetabulum. The acetabulum appeared well fixed. Once these were removed, the hip was again thoroughly lavaged with saline.

A constrained liner was inserted and then tapped into the acetabular shell with good fixation. A locking trial was then placed over the trunnion and the femoral head was tapped onto the Morse taper of the stem with a good fit. The hip was reduced, and similar to previous findings, it was noted to be impinging anteriorly on what was felt to be the lesser trochanter. I did mobilize this area and with the added offset from my femoral head, the patient had good stability up to around 80 degrees of flexion. The locking mechanism was then advanced over the polyethylene liner and tapped into place. This appeared to provide appropriate added stability. The hip was again lavaged with saline and then closed in a layered fashion. The limb lengths were felt to be restored with probably some 5 mm and 1 cm shortening on the opposite side.

A #2 PDS suture was placed in a figure-of-eight interrupted fashion on the gluteus fascia. There were no deep external rotators or soft tissues which could be mobilized to the greater trochanter. The deep subcutaneous layer was closed with a 0 Vicryl in a simple interrupted fashion, and the superficial subcutaneous layer was closed with 2-0 Vicryl in a buried interrupted fashion. The skin was closed with staples and the area was washed and dried. A dressing consisting of Xeroform, 4x4’s, an ABD, and Micropore tape was applied. The drapes were removed and the patient was returned to the supine position. An abduction pillow was inserted and an SCD and TED hose were placed on the operative side. The patient was awakened from anesthesia, extubated, and taken to the recovery room on her hospital bed in stable condition. There were no complications noted during the case.

Estimated Blood Loss: 175 cc

Anesthesia: General

Disposition: The patient will be admitted to the floor with weight-bearing, as tolerated. I am going to limit hip flexion to less than 80 degrees. She will maintain strict posterior hip precautions. She will start chemical DVT prophylaxis in the morning. We are going to continue with gram-negative coverage for her previous infection and then she will have routine postoperative gram-positive coverage.

Code the previous scenario with CPT procedure and ICD-9-CM diagnosis codes.


Answers:

CPT Code
27134-LT Revision of total hip arthroplasty; both components, with or without autograft or allograft

Rationale: In the 2014 CPT index, main term Arthroplasty and subterms hip and revision, the coder is directed to see code range 27134-27138. Review of the descriptor for code 27134 “revision of total hip arthroplasty; both components, with or with autograft or allograft” identifies this as the correct code. Append HCPCS Level II modifier LT to the procedure code to indicate the procedure was performed on the left side.

The prosthetic components would be assigned with HCPCS Level II codes by the hospital or facility where the procedure was performed. The surgeon bills only for the surgical service provided.

ICD-9-CM Diagnosis Codes
996.42 Dislocation of prosthetic joint
890.0 Open wound of hip and thigh, without mention of complication
V43.64 Organ or tissue replaced by other means, joint, hip

Rationale: In the ICD-9-CM alphabetic index, under the main term Wound and subterm hip, the coder is directed to code 890.0. Confirmation in the tabular index states that the fourth digit 0 is for a wound to the hip without mention of complication.

For the recurrent dislocation of the prosthetic hip, see Complications, mechanical, prosthetic, joint, dislocation which directs the coder to code 996.42 Dislocation of prosthetic joint. A Use additional code note is provided under category 996.4 Mechanical complication of internal orthopedic device, implant, and graft, which instructs the coder to assign a code from subcategory V43.6 Organ or tissue replaced by other means, joint, to identify the prosthetic joint with mechanical complication. The fifth-digit subclassification 4 identifies the hip joint.

 
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