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By Indra Osi, RHIA, CHP
Recently, there has been discussion regarding the appropriate code to use when describing the aftercare that is performed when a fracture has been repaired with a joint replacement. The issue raised concerns whether the fracture would be considered a condition that no longer exists (since the joint was removed and replaced) and therefore would not be coded as a subsequent encounter for a fracture.
Previous ICD-9-CM advice would seem to suggest that the focus should be on the fact the patient had a joint replacement rather than on the fracture. In response to a question regarding aftercare provided to a patient that had a intertrochanteric hip fracture repaired through a total hip replacement, the 2009 First Quarter Coding Clinic for ICD-9-CM, page 6, stated:
“Assign code V54.81, Aftercare following joint replacement, and code V43.64, Organ or tissue replaced by other means, joint, hip, for this encounter. Each code represents a different piece of information regarding the aftercare and is needed to fully describe the encounter.
Code V54.13, Aftercare for healing traumatic fracture of hip, is not appropriate since there is no fracture; the hip has been replaced by a prosthetic joint.”
This advice, while appropriate at that time, does not reflect current coding practice, based on updated official coding advice. The Third Quarter 2016 Coding Clinic for ICD-10-CM/PCS (pages 16-17) provided the following advice for ICD-10-CM coding:
“7th character assignment for rehab admission following femur fracture and hip replacement
A patient was admitted to an acute rehab facility for physical and occupational therapy following a total hip replacement (THR) due to a right intertrochanteric femur fracture. Since the hip joint was removed and replaced with a prosthetic, would the femoral fracture still be coded?
In this case, a total hip replacement was done to treat the traumatic fracture of the hip. The fracture is now in the healing and recovery phase after surgical treatment. Assign code S72.141D, Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, as principal diagnosis. Assign also code Z96.641, Presence of right artificial hip joint.
The intent of ICD-10-CM’s seventh character for fracture and other injuries is to track treatment through the various stages, as well as to track resource utilization and outcomes. There are clinical differences in joint replacement surgery performed because of a traumatic fracture versus elective joint replacement surgery. For example, an injury resulting in unexpected surgery might require more intensive rehabilitation than a hip replacement due to degenerative osteoarthritis of the hip.”
There are clinical differences in joint replacement surgery performed because of a traumatic fracture versus elective joint replacement. Advances in clinical practice and thinking, as well as the transition to a new classification system, led to a change in the proper coding of aftercare following a joint replacement for a fracture. Having the ability to correctly code this scenario based on the etiology is a result of the increased specificity allowed in ICD-10.
Following the guidance provided in the Third Quarter 2016 issue of Coding Clinic for ICD-10-CM/PCS will help ensure accurate capture of this event and allow for compiling information that will assist in appropriate treatment and payment for these services.
Indra Osi (OSII@ccf.org) is director, coding and reimbursement at Cleveland Clinic.