Orthopedic surgeons play a critical role in diagnosing and treating musculoskeletal conditions to help patients regain mobility and stability and improve their quality of life. To engage with patients and solve their problems, orthopedic surgeons and clinics need a billing system that oversees all collections. However, navigating the intricacies of medical billing, CPT coding, reimbursement, and revenue capture can be challenging. Medical coders must have a general understanding of the procedures they are coding and be able to associate medical jargon with the formal medical terminology used in code descriptions.
CPT (Current Procedural Terminology) codes function as the universal language for communication between healthcare providers, payers, and billing entities. This article explores the key considerations that empower orthopedic surgeons to decode and document Total Hip Arthroplasty (THA) effectively.
Introduction to Hip Replacement and Revision Coding
Approximately 35% of joint replacement surgery claims are erroneous, with 25% of the medical claims being denied.
Understanding The Basics
Total Hip Arthroplasty (THA), also known as hip replacement, involves the removal of diseased cartilage and bone from the acetabulum and femur, which is then replaced with prosthetic components. First, the femur is hollowed out, and then the femoral head is removed. For the replacement, a metal stem is cemented directly into the hollowed-out femur, and then a metal or ceramic ball (head) is attached to the top of the stem. The surface of the acetabulum is then reamed out and inserted with a metal socket or cup. The socket is secured with screws or cement, and a spacer, sometimes also called a liner, is inserted between the ball and socket to create a smooth surface for the new joint to glide.
While hip replacements relieve pain and restore hip joint function, they do not last forever. A successful hip replacement typically lasts about 15 years, and some patients require at least one hip replacement revision in their lifetime. This is particularly the case if the hip replacement surgery was performed at a young age, the patient has a very active physical lifestyle, or the initial replacement surgery bore complications.
Hip revision surgery involves removing one or more prosthetic components and replacing them with new ones. Common reasons for a hip revision include recurrent dislocation of the prosthetic joint, infection, and mechanical failure.
The Importance of Accurate Coding
Accurate coding ensures transparent communication between healthcare providers and payers while facilitating proper reimbursements for services rendered during hip replacement procedures. Staying current with the latest coding practices and industry trends ensures clarity in patient records, enables proper billing, and eliminates errors that could compromise patient care.
Key Codes and Guidelines for Hip Replacement
Coding for hip replacement and revision is far less daunting when you have the correct information. To position yourself for excellent coding, take the time to familiarize yourself with hip joint anatomy and the structure of the hip replacement components.
Identifying the Right Codes
The CPT code for total hip replacement is 27130 Arthroplasty, acetabular, and proximal femoral prosthetic replacement, with or without autograft or allograft.
CPT codes for hip revision include a combination of steps usually performed together. Removal, re-insertion of components, and often bone grafts. The code includes:
- 27132: Conversion of hip surgery to total hip arthroplasty
- 27134: Revision of total hip arthroplasty: both components, with or without autograft or allograft
- 27137: acetabular component only, with or without autograft or allograft
- 27138: femoral component only, with or without autograft or allograft
For removal of hip prosthesis without concurrent revision or replacement, check the 27090 – 27091 code series.
Navigating Through Common Challenges
The intricate nature of orthopedic surgeries and treatments often demands the use of specific codes that precisely capture the essence of the procedure. In 2013, the CPT Manual introduced multiple coding changes and revisions that greatly affected orthopedic reimbursement. There is also the shift to ICD-10 that left practices with limited resources struggling to meet requirements and maintain profitability. It is now compulsory to document the specific areas of the body treated in terms of left, right, or bilateral for conditions like joint disorders.
In addition, surgery cases are often complex, and multiple procedures may be needed to resolve a patient’s problem. Coders need to be aware of the CPT guidelines and pay attention to the wording of the physical documentation.
Advanced Insights into Hip Revision Coding
CPT codes for hip revision surgeries vary based on factors such as the complexity of the procedure, the components replaced, and the approach used.
Distinguishing Between Primary and Revision Procedures
Primary procedures involve the first-time placement of prosthetics to address joint issues. Conversely, revisions occur when the original hip replacement needs correction due to complications or problems such as wear and loosening. Proper coding relies on precisely identifying whether a hip replacement surgery is a primary or a revision.
Tips for Complex Cases
Accurately capture the underlying cause for the replacement surgery and any infections or dislocations in the replaced hip. Overlooking factors such as diagnosis when reporting hip replacements could omit important reimbursement components. Surgeons must document any additional work or undue time spent on a case. Sometimes, a diagnosis alone does not support the medical need for reporting with a modifier. The documentation must clearly state why a case was more complex than average.
Staying Updated with Latest Coding Practices
Medical coding is subject to continuous updates and modifications, making it crucial to stay informed to ensure precise coding and billing. Some of the ways to ensure you stay up-to-date with code revisions include:
Resources for Continuous Learning
Subscribe to updates and publications from organizations responsible for reviewing and updating the codes. These include the American Medical Association (AMA) and the World Health Organization (WHO). These can be vital resources for providing valuable insights to stay current on the latest changes.
Opt-in and Outsource to CBS Medical Billing and Consulting
Effectively documenting hip replacement surgeries is vital to ensure successful claim submission and reimbursements. When you thoroughly report a patient’s encounters, including their history, physical examination findings, and treatment plans, you properly reflect the medical necessity of the services provided.
As an orthopedic medical practitioner, your hands may already be full. Therefore, delegating the billing and coding tasks over to professionals makes sense. CBS Medical Billing and Consulting, LLC provides professional billing and coding services. Contact us today to help you offload the administrative burden of billing so that you can focus on patient care.
