How To Use CPT Code 27258

CPT 27258 describes the open treatment of a spontaneous hip dislocation, including congenital or pathological cases, and the replacement of the femoral head in the acetabulum. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 27258?

CPT 27258 is used to describe the open treatment of a spontaneous hip dislocation, including cases that are congenital or pathological. This procedure involves the replacement of the femoral head in the acetabulum, which is the cup-shaped socket of the hip joint. It may also include a tenotomy, which is the division of a muscle tendon. The purpose of this procedure is to realign the femur head into the acetabulum and provide stability to the hip joint.

2. Official Description

The official description of CPT code 27258 is: ‘Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc).’ This code specifically refers to the surgical procedure of open treatment for hip dislocation, involving the replacement of the femoral head in the acetabulum.

3. Procedure

1. The provider begins by performing an adductor tenotomy, which involves dividing the adductor muscle tendon.
2. Next, the provider makes an incision over the hip joint capsule and exposes the joint.
3. Multiple incisions are made over the labrum surrounding the margin of the acetabulum to increase the size of the cavity.
4. This allows for the reduction, or realignment, of the femoral head into the acetabulum.
5. The provider sutures the joint capsule tightly to provide extra stability to the hip joint.
6. Tendons are reapproximated and sutured, and the iliac epiphysis is reattached to the ilium.
7. The provider stops any bleeding and closes the wound by suturing the soft tissues in layers.
8. After the procedure, the patient may be placed in a brace or a spica cast to support the hip joint.

4. Qualifying circumstances

CPT 27258 is performed on patients with a spontaneous hip dislocation, which can be developmental, congenital, or pathological in nature. The procedure is indicated when there is an abnormal separation of the hip joint, requiring open treatment and the replacement of the femoral head in the acetabulum. The provider may also perform a tenotomy as part of the procedure. It is important to note that this code is specific to the open treatment of hip dislocation and should not be used for other hip procedures.

5. When to use CPT code 27258

CPT code 27258 should be used when the provider performs an open treatment of a spontaneous hip dislocation, including congenital or pathological cases, and replaces the femoral head in the acetabulum. This code is not appropriate for other hip procedures or treatments. It is important to accurately document the details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT code 27258, the provider must document the following information:

• Patient’s diagnosis of spontaneous hip dislocation
• Description of the procedure performed, including the open treatment and replacement of the femoral head in the acetabulum
• Details of any additional procedures performed, such as a tenotomy
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Post-procedure instructions and any follow-up care
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 27258, ensure that the procedure performed meets the criteria for open treatment of a spontaneous hip dislocation and replacement of the femoral head in the acetabulum. It is important to accurately document the details of the procedure to support the use of this code. This code should not be reported with other hip procedure codes unless there are additional procedures performed that are separately reportable. It is also important to follow any specific billing guidelines provided by payers or regulatory authorities.

8. Historical information

CPT code 27258 was added to the Current Procedural Terminology system on January 1, 1990. There have been several historical changes to this code, including being added and removed from the Inpatient Only (IPO) list for Medicare. It is important to stay updated on any changes or updates to the code to ensure accurate billing and coding practices.

9. Examples

1. A patient presents with a spontaneous hip dislocation due to a congenital condition. The provider performs an open treatment, including the replacement of the femoral head in the acetabulum, and a tenotomy. CPT code 27258 would be used to bill for this procedure.
2. Another patient has a pathological hip dislocation. The provider performs an open treatment, including the replacement of the femoral head in the acetabulum, without the need for a tenotomy. CPT code 27258 would be used to bill for this procedure.
3. A third patient has a developmental hip dislocation. The provider performs an open treatment, including the replacement of the femoral head in the acetabulum, and a tenotomy. CPT code 27258 would be used to bill for this procedure.