You are on page 1of 20

Coding of Total Joint Procedures

Update 2009

Duke Hip and Knee Conference


David E. Attarian, M.D., F.A.C.S.
ICD-9-CM
 International Classification of Diseases, 9th
Revision, Clinical Modification- published
under different names since 1900.
 A statistical classification system arranging
diseases and injuries into groups; revised
about every 10 years by the World Health
Organization. Adopted by CMS.
 Currently about 14,000 codes
ICD-9-CM
 In the 1950’s, U.S. Public Health Service
and Veterans Administration adopted
classification system for hospital indexing
purposes. Other hospital systems followed.
 The Medicare Catastrophic Coverage Act of
1988 mandated that ICD-9-CM codes be
used for billing beginning April 1, 1989.
CMS Requirements
 Uniform Health Insurance Claim Form, CMS1500, must list
at least one but no more than four ICD-9-CM codes per
encounter or service.
 Submit the most specific code possible, 3 to 5 digits.
 Failure to use ICD-9-CM codes may be punished with fines
of $2000 per claim or prevention from participation in
Medicare for up to 5 years.
 ICD-10-CM will be mandated by CMS (then all payors must
follow) on October 1, 2013. Has 68,100 codes, 3 to 7 digits.
Supports quality and P4P reporting.
 Upgraded Health Insurance Portability and Acountability
requirements (4010 to 5010) starts 2010 and required in
2012.
Diseases of the Musculoskeletal
System and Connective Tissue
710-730
 Most common for total joints-
osteoarthrosis 715, crystal arthropathies
712, and rheumatoid arthritis 714.
 Primary osteoarthrosis of hip- 715.15
 Generalized osteoarthosis involving knee-
715.06
Complications of Surgical and
Medical Care, Not Elsewhere
Classified
 Infected joint prosthesis- 996.66
 Mechanical complication of internal
orthopaedic device, implant, or graft- 996.4
New Codes
 996.41- mechanical loosening of prosthetic
joint
 996.42- dislocation of prosthetic joint
 996.43- prosthetic joint implant failure or
breakage
 996.44- periprosthestic fracture around
prosthetic joint
New Codes
 996.45- periprosthetic osteolysis
 996.46- articular bearing surface wear of
prosthetic joint
 996.47- other mechanical complication of
prosthetic joint implant
 996.48- bone graft failure
DRG(Diagnosis- Related Group)
Updates
 Formerly DRG 209- all hip/ knee arthoplasty
 Changes October 2005-
 DRG 544- primary hip/ knee arthroplasty
 DRG 545- revision hip/ knee arthroplasty
 Changes October 2007
 MS-DRG- MCC, CC, or without MCC/CC
 HHS developed ICD-10 PCS for hospitals.
CPT- Current Procedural
Terminology (AMA-1966)
 Systematic listing and coding of procedures and
services performed by physicians.
 Each procedure or service has a 5 digit code.
 Service must be supported by an appropriate ICD-
9-CM code.
 Musculoskeletal System 20000- 29999
 Updated annually (October for coming year)
 Relative Value Units (RVU) assigned to each
CPT.
Old Hip Arthroplasty Codes (I)
 27125- hemiarthroplasty
 27236 hemiarthroplasty for fracture
 27130- total hip with/ without bone graft
 27132- conversion of previous hip surgery to total hip arthroplasty
 27134- revision total hip, both components, with/ without bone
graft
 27137- hip revision, acetabulum only
 27138- hip revision, femur only
 27090- removal of hip prosthesis
 27091- complicated removal of hip prosthesis, cement, with/
without insertion of spacer
 27299- unlisted procedure/? resurfacing
New Codes
 00.70- revision both components
 00.71- revision acetabular component +
femoral head
 00.72- revision femoral component +
acetabular liner
 00.73- isolated revision of head + liner
 84.56- insertion of cement spacer
 84.57- removal of cement spacer
Old Knee Arthroplasty Codes
 27438- patellar prosthesis
 27445- knee hinge prosthesis
 27446- unicompartmental arthroplasty
 27447- total knee with/ without patellar
resurfacing
 27486- revision, one component
 27487- revision, femur and tibial components
 27488- removal of prosthesis, with/ without
insertion spacer
 27599- unlisted procedure
New Codes
 00.80- revision of all components
 00.81- revision of tibial component/ insert
 00.82- revision of femoral component
 00.83- revision of patellar component
 00.84- isolated revision of tibial insert
 84.56- insertion of cement spacer
 84.57- removal of cement spacer
Physician Quality Reporting Initiative-
PQRI (Medicare Improvement for
Patients and Providers Act (MIPAA)
 Timing of antibiotics- 4047F (ordered)
4048F(given)
 Selection of antibiotic- 4041F (ordered/given)
 Discontinuation of antibiotics- 4049F (ordered)
 VTE prophylaxis- 4044F (ordered/given)
 1.5% bonus 2007/2008, 2% bonus 2009 by
reporting 3 out 4 quality measures on 80%
eligible Medicare patients (provider or group)
Modifiers
 -51- bilateral
 -53- discontinued after starting
 -58- staged or related during global period
 -59- distinct procedural service
 -78- return to OR for related procedure
 -79- return to OR for unrelated procedure
 -80- assistant surgeon
 -22- unusual/ extraordinary work effort
T codes- Emerging Technology ( III)
Computer Assisted Surgery
 Primary CPT+

 0054T*- CAS based fluoroscopic images


 0055T*- CAS based CT or MRI images
 0056T*- CAS based imageless technology
 Had CPT in 2008; recycled to III in 2009*
 Reimbursement is variable/ payor dependent.
Examples
 Bilateral total knees for osteoarthritis-
715.16/ 27447.50
 Return to OR for hip revision secondary to
recurrent dislocation during global period-
996.42/ 00.71.78 (acetabulum/femoral
head)
 Unspecified codes- e.g. hip resurfacing
 Coders must also indicate place of service
and inpatient/ outpatient status.
Examples
 2 stage knee revision in a global period: 27488
for removal/spacer; 27447-58,22 for
reimplantation
 2nd stage reimplantation from another surgeon:
27447-22, and removal of drug non
biodegradable implant, 11982.51.
 2nd stage reimplant total hip/remove spacer
outside global period: 27132-22
Recommendations
 Become intimately familiar with ICD-9-CM and CPT
books/ update programs or books each year
 New training will be needed in advance of ICD-10-CM
implementation
 Take a coding course at least once (AAOS or AMA
sponsored).
 Always code correctly and ethically; document service in
medical record. Coding must match record exactly. Coding
“mistakes” can be interpreted as fraud (which is a felony
punishable by fine, loss of payor privilege, and/or
imprisonment).
 Use professional coders or coding service; Duke has
PRMO.