Coding, Classification & Reimbursement

Open Approach vs Percutaneous Fixation

  • 1.  Open Approach vs Percutaneous Fixation

    Posted 02-23-2018 15:15
    ​​Help!! Would you code the following as open or percutaneous fixation as the surgeon has listed?

    PREOPERATIVE DIAGNOSIS: Intertrochanteric fracture of the right hip.

    POSTOPERATIVE DIAGNOSIS: Intertrochanteric fracture of the right hip.

    PROCEDURE: Closed reduction, percutaneous fixation with a Gamma nail.

    After the correct side was identified by our time-out procedure, the patient was placed on the fracture table and the fracture was reduced under C-Arm control. The patient was then prepped and draped in the appropriate fashion. A small incision was made over the greater trochanter and a guidewire was placed down the canal. This was then reamed to accept the Gamma nail and then a longer guidewire was used and the canal was reamed up to 12. An 11-millimeter short nail, 125 angle, then was impacted into place. The guidewire placed across the intramedullary device and up into the head a very small distance from the articular surface. This was reamed and 100-millimeter screw was placed up into the head and then compressed about an inch. The screw was then locked using the special locking screw. Attention was brought to the distal screw where using the static guide, a 37.5 screw was placed through the locking hole, and the entire procedure was documented in the C-Arm. Copious irrigation at the proximal wound with dilute Betadine, then the iliotibial band was closed with #0 Vicryl, 2-0 Vicryl in the next level, and Quill in the skin, a silver occlusive dressing. The two stab wounds were closed with 4-0 Prolene and silver occlusive dressing. The patient was taken to the Recovery Room in satisfactory condition.


    Any help would be greatly appreciated!!

    Thanks!



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    Kayla Hill, RHIA
    Director of Health Information/Privacy/CDI
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  • 2.  RE: Open Approach vs Percutaneous Fixation

    Posted 02-24-2018 11:33
    Edited by Lawrence Barr 02-24-2018 11:40
    ​Hello!

    Please see Coding Root Operations with ICD-10-PCS: Understanding Transplantation, Reattachment, Transfer, and Reposition .  The example for Reposition is exactly the same as yours except it involves the left rather than right upper femur.  The Approach for CRIF's is based on how the internal fixation device is placed, not the reduction.  The definition of Percutaneous Approach is "Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure.  Assign code OQS636Z - Reposition R Upper Femur w Internal Fixation Device, Intramedullary, Percutaneous Approach.

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    Lawrence Barr
    President
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  • 3.  RE: Open Approach vs Percutaneous Fixation

    Posted 02-25-2018 08:43
    This was a percutaneous procedure where a small incision is made to complete the procedure. Open procedures would be an incision to reach the site of the procedure that's being operated on.

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    Magdala Andre
    Coding Educator
    Capital Health System
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  • 4.  RE: Open Approach vs Percutaneous Fixation

    Posted 02-25-2018 09:49
    Kayla,

    I hope you don't mind if I piggyback on your question. I've been using the same code Lawrence suggested, but have had some recent doubts ( agree with percutaneous). When I look up medullary canal of the femur, it appears to start in the shaft. The neck and trochanteric areas of the femur are spongy bone. I have been coding a trochanteric fracture as an intramedullary fixation, but I'm wondering now if it should be internal fixation instead. Should intramedullary still be coded to indicate the nail was placed down the center of the bone instead of some type of fixation on the outside of the bone? Just wondering if anyone else has any thoughts on this.

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    Laurie Zawiskie
    Coder III
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  • 5.  RE: Open Approach vs Percutaneous Fixation

    Posted 02-26-2018 05:28
    Edited by Lawrence Barr 02-26-2018 05:33
    ​Hello!

    Please see the article Intramedullary gamma nail fixation .  This is one of numerous articles on the subject.  "Fractures of the neck of the femur and of the trochanteric region are typical injuries of the elderly. Stable fixation of these fractures can be obtained using a special intramedullary nail known as the gamma nail." The Root Operation is Reposition and the site being treated is the proximal femur.  Also, placement of an internal fixation device at this site would probably require an open approach.

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    Lawrence Barr
    President
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  • 6.  RE: Open Approach vs Percutaneous Fixation

    Posted 02-26-2018 20:34
    Edited by Laurie Zawiskie 02-26-2018 21:04
    It makes sense now. It's more about the type of device (intramedullary nail) used rather than where the device is placed (medullary canal vs spongy bone). Thanks, Lawrence!

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    Laurie Zawiskie
    Coder III
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