An ambulatory 15-year-old patient presented with complaints of hip pain secondary to dislocated left hip. She underwent left femoral head resection. In this case, the left femoral head and proximal femur were excised. Per the ICD-10-PCS body part key, femoral head refers coders to use “upper femur.” Should the root operation be excision or resection? What components are considered part of the “upper femur” body part?
The excision of the femoral head and proximal femur equates to upper femur, and therefore, the root operation resection should be reported. According to the operative report, the femur was divided in the subtrochanteric region (below the greater and lesser trochanter). This region is the border between the upper femur and the shaft, and therefore the entire upper femur was cut out. Assign the following ICD-10-PCS code for the procedure performed:
0QT70ZZ Resection of left upper femur, open approach