A patient with painful right total knee arthroplasty presents for revision of the arthroplasty. The previous components were removed and new tibial and femoral components were inserted and cemented into place. Should this be coded as a revision or replacement procedure?
Since the components were removed and replaced, this procedure should be coded as a replacement procedure. Additionally, the removal of the previously placed components should be separately reported. For the procedures performed, assign the following ICD-10-PCS codes:
0SRC0J9 Replacement of right knee joint with synthetic substitute, cemented, open approach
0SPC0JZ Removal of synthetic substitute from right knee joint, open approach
Although revision may be documented by the surgeon, according to the ICD-10-PCS’ definition of the root operation “Revision,” a revision should be reported when the objective of the procedure is to correct the position or function of a previously placed device, without taking out and putting a whole new device in its place. A complete redo of a procedure is coded to the root operation performed, in this case, a removal and replacement.