Author: Kimberly Mansingh

Article

Antibiotic Spacer Removal Followed by Total Hip (CPT 27132 or 27134)?

Kimberly Mansingh

Q. A patient had a total hip arthroplasty last year, but due to infection, the prior total hip (both acetabular and femoral components) had to be removed. In their place, the surgeon inserted a static antibiotic spacer. The patient now presents four months later after the infection resolved and is ready for a new total hip. How are the removal of the antibiotic spacer and the insertion of the new total hip (again both acetabular and femoral components) coded?

A. Assign CPT 27132: Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft. This code will include the removal of the spacer, the insertion of a new total hip (both acetabular and femoral components), and any bone grafting that may be necessary (note that bone grafting is not required but it is included when performed).

Coding Tips: While you may be tempted to code CPT 27134: Revision of a total hip arthroplasty, both components, with or without autograft or allograft instead since the patient had a total hip arthroplasty in the past, it’s important to note that this code represents removal of a total hip with insertion of a new total hip during the same operative session. In a case where the patient already had the original total hip removed in an earlier surgery and was left with a static antibiotic spacer, code 27134 would not be accurate since there are no total hip components to remove.

Articulating vs. Static Spacers: It’s also important to understand that antibiotic spacers can be static or articulating. Static spacers such as the one featured in the question above are inserted to resolve infection after the infected joint prosthesis is removed and provide no mobility for the joint. Articulating spacers on the other hand are specialized antibiotic spacers that contain a femoral stem and a modular head that allows for some mobility of the hip while the infection is resolving. Articulating spacers reduce the risk of joint contracture because of immobility in the joint and may be used for patients who have a prolonged infection that must be resolved before the new total hip can be inserted.

In an operative report that describes removal of an articulating spacer followed by insertion of a new total hip, you might see language that reads “we then turned our attention to the femoral stem” or “the femoral component was then removed.” This can be confusing because a permanent hip prosthesis also has a femoral component (sometimes referred to as a femoral stem). Seeing this language may lead a coder to conclude that the patient still had one of the permanent components from the original total hip in place and create confusion around whether to code 27132 or perhaps 27134 or even 27138. With that said, we would not expect to see a patient with a component of a permanent hip prosthesis and an antibiotic spacer at the same time so that referral to a “femoral stem” or a “femoral component” is generally just part of an articulating spacer (which is a temporary implant not a permanent prosthesis).

Coding Caveat? Until this year, the guidance for coding removal of a static or an articulating spacer followed by insertion of a new total hip has been the same: report CPT 27132. At the AMA Symposium in late 2019, though, the American Academy of Orthopedic Surgery (AAOS) outlined some new proposed guidance for coding this type of two-stage joint replacement when an articulating spacer is involved. Instead of recommending 27132 for removal of the articulating spacer followed by insertion of a new total hip, the AAOS suggested reporting 27134 instead because the work of removing an articulating spacer is similar to that of removing the original permanent hip prosthesis. While I certainly agree with that thought, I have not seen new guidance from the AMA or CMS supporting this new recommendation just yet. Typically, once authoritative guidance from these agencies is published, insurance carriers will align with the new guidance, making it easier to get your claims paid following the new rules. So for now, I continue to use the 27132 following the historical guidance (adding modifier 22 for increased complexity associated with removal of an articulating spacer when supported by the documentation). I am also keeping an eye out for any references from these agencies that aligns with the AAOS recommendation to report CPT 27134 for a surgery where an articulating spacer is removed and a new total hip is inserted and will update this article once such guidance is received. In the interim, I would encourage you to discuss this surgery with your top payers and your internal team at your organization to ensure accurate and optimal coding.

References: CPT Assistant, December 1, 2008, copyright American Medical Association

International Journal of Medical Sciences, copyright Ivyspring International Publisher (source for overview of static vs. articulating spacers) Static vs. Articulating Spacers

Article

Partial Colectomy vs. Partial Colectomy with Ileocolostomy

Kimberly Mansingh

Q. Can you explain the difference between CPT codes 44140 and 44160? Both codes represent a partial colectomy, and I am unclear on what work must be performed after the colectomy to choose between the two codes.

A. These two codes often generate confusion for surgical coders. The confusion usually stems from uncertainty about what the term “ileocolostomy” which appears in the description of CPT 44160 means and what part of the bowel is removed in each procedure. Before we break down the definitions of both codes, if you are a visual learner and want a refresher on the anatomy of the colon, check out this image: Segments of the Colon Explained

  • CPT 44140 includes a partial colectomy with an anastomosis (reconnection) of two ends of remaining colon in the body. The anastomosis created during this procedure is a “colo-colonic” (or colon to colon anastomosis). For example, if a laparotomy incision is made and part of the ascending colon and the transverse colon are removed followed by an anastomosis between the remaining ends of the ascending and transverse colon, CPT 44140 should be coded. The same would be true for an open approach with partial removal of any part of the colon followed by anastomosis of the remaining two ends of the colon (e.g., removal of the descending colon with anastomosis between the sigmoid and the transverse colon, removal of the transverse colon and ascending colon with anastomosis of the cecum and the descending colon, etc.).
  • CPT 44160 on the other hand represents excision of part of the colon and excision of the terminal ileum (the end of the last segment of the small intestine) followed by an ileocolostomy. The term ileocolostomy is often confusing because, in other colectomy codes where we see a term ending in “-ostomy” (colostomy, ileostomy, etc.), the “ostomy” refers to bringing the remaining end of the colon up to an opening created in the abdominal wall. A bag is then attached and feces leave the body through that artificial opening. At its most basic level, though, the suffix “-ostomy” simply means to “create an opening” or to “create a new connection.” So the term ileocolostomy means “to create a new connection between the ileum and the colon.” When we look at the description of CPT 44160 with this new understanding, the procedure represented by this code becomes clearer. To code CPT 44160, the documentation must support 1) removal of part of the colon, 2) removal of the terminal ileum, and 3) an anastomosis (new connection) between the remaining ileum and the remaining colon. For example, if a laparotomy incision is made, the terminal ileum and cecum are removed, and the ascending colon and the remaining ileum are anastomosed, CPT 44160 should be coded. Again this code is appropriate when any part of the colon and terminal ileum are removed through an open approach and an ileocolonic anastomosis (aka an ileocolostomy) is created (e.g., the terminal ileum, cecum, ascending, and part of the transverse colon are all removed and the remaining transverse colon and ileum are anastomosed).

For those of you coding laparoscopic colectomies, the same explanation provided above for CPT 44140 and 44160 also applies to CPT codes 44204 and 44205 in the laparoscopic world. CPT 44204 is for a laparoscopic approach with removal of part of the colon and a colocolonic anastomosis while CPT 44205 is for a laparoscopic approach with removal of part of the colon and the terminal ileum followed by an ileocolostomy.

Understanding the terminology in the code descriptions as well as the anatomy of the colon and the small intestine are keys to coding surgeries these surgeries accurately.