AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Issue 3; Ask the Editor
Resection of Femur with Interposition Arthroplasty
The patient is a 14-year-old male with known quadriplegic-pattern cerebral palsy and bilateral hip dislocations with degenerative changes. The patient is admitted to undergo resection arthroplasty in which a resection of the proximal femur with interposition arthroplasty by muscle transfer is performed along with right open adductor longus and brevis tenotomies which were tenotomized by cautery. Per the operative note, the entire left and right upper femur was removed. Should the resection of the proximal femur with interposition arthroplasty by muscle transfer be coded to the root operation “Excision” (femoral head) plus “Reposition” or “Transfer” (muscles), or perhaps with the root operation “Replacement” to encompass both components? ...
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Article Overview
This article examines an ICD-10-PCS orthopedic coding scenario involving femoral resection arthroplasty, muscle interposition, and associated tendon procedures in a patient with cerebral palsy and hip dislocation. It is intended for coders and CDI professionals who need to understand how the procedure is approached within ICD-10-PCS and how the associated procedure components are organized for coding review.
Why This Topic Matters
Orthopedic procedures that combine bone resection with soft-tissue work can be difficult to classify correctly in ICD-10-PCS, especially when multiple operative components are documented in the same case. This article helps readers assess the coding impact of a complex hip salvage procedure.
What You Will Learn
- The clinical context for a complex pediatric hip salvage procedure
- How the article frames the ICD-10-PCS coding question for the operative note
- How the associated soft-tissue procedures relate to the main surgical procedure for coding review
- What broad procedure components are being considered in the coding discussion
Who Should Read This
- Inpatient coders
- Coding auditors
- Clinical documentation integrity specialists
- Orthopedic coding professionals
Codes Discussed
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