SLIDE 1: Hip and Knee Replacements and Revisions in ICD-10-PCS
Presented by:Karl Koenig, MD
Representing:
The American Academy of Orthopedic Surgeons (AAOS)
The American Association of Hip and Knee Surgeons (AAHKS)
The American Joint Replacement Registry (AJRR)
September 23, 2014

SLIDE 2: Who we are
-AAOS: Organization of over 35,000 orthopedic surgeons in the US and around the world
-AAHKS: Surgeons who perform mostly hip and knee replacements with over 2,000 members in the US
-AJRR: Organization established to monitor hip and knee replacement implants in order to improve patient outcomes after joint replacement

SLIDE 3: Goals
-Continue to maintain device quality control and improve patient outcomes.
-Assist with a smooth transition to ICD-10-PCS procedure codes while improving our ability to track patient outcomes and maintain appropriate implant registries.
-Suggest changes in areas where ICD-10-PCS coding logic does not adequately mesh with the reality of clinical practice to ensure consistent coding and reporting.

SLIDE 4: What we are proposing
-7 separate recommendations for modifications to ICD-10-PCS for hip and knee replacements
--Differentiate procedures that are currently reported in ICD-9-CM 
--Simplify the reporting of revision joint replacements for hospital coders and improve consistency across related procedures

SLIDE 5: Summary of recommendations
-Add new device code for partial hips (endo-femoral device)
-Add resurfacing device code to 0SR9/B root operation
-Add new device code for unicondylar knee
-Add new device code for patellofemoral joint replacement
-Add body parts for hips and knees to 0SP root operation for removal of prostheses;
 create new body part for patellar surface
-Modify index entries for hip/knee revisions to ensure proper coding
-Change name of device code from “Liner” to “Bearing surface”

SLIDE 6: Why this is important
-Hip and knee replacements are very widely performed procedures in most US hospitals and communities
-2012 number of joints: 289,800 total hips, 109,900 partial hips, 589,000 total knees, 61,400 revision hips, 71,100 revision knees

SLIDE 7: AJRR Registry goals
-Register total hips and knees in national database
--Approximately 300 hospitals participating as of 7/31/2014
--Longevity of the devices and low failure rate requires a national registry in order to identify issues
-Examine outcomes
--Survivorship defined as death or revision of joint replacement
-Conclusion: Reporting of revisions critical for integrity of AJRR and similar registries

SLIDE 8: Survivorship of different hip implant systems
-Conclusion: ASR has poorer survivorship compared to other systems.
-Resulted in J&J recall of device, $6.8 billion legal settlement.

SLIDE 9: Anatomy of hip
-Image showing a skeletal depiction of a human pelvis with inset close-up of hip joint

SLIDE 10: Reasons for hip replacements
-Total Hip Replacement or hip resurfacing:
--Osteoarthritis
--Osteonecrosis-
Partial Hip Replacement
--Fracture
--Tumor

SLIDE 11: Hip fracture
-Most common hospitalized fracture in the US (over 300,000 each year)
-Treated by variety of physicians
-Location of fracture can dictate treatment
-Overlap of treatment can distort objectives of joint registries

SLIDE 12: Hip Fracture Overview
-Image displaying a hip and location and names of different fractures of hip
-Pie graph of the types of hip fractures -- Femoral neck was 50.5%, Intertrochanterics was 44.3%, and sub-trochanteric was 5.3% of hp fractures.
-Image displaced and non-displaced hip fracture
-Images of non-arthroplasty treatments for hip fracture including hip pins, sliding hip screw, and cephalomedullary nail.
-Images of arthoplasty treatments for hip fracture including total hip and partial hip
-Graph of trends in treatment of femoral neck fractures -- Partial hips were 60%, Total hips 7%, ORIF (Open Reduction, Internal fixation was 25%)
-Fracture displacement is key: If displaced, then blood supply is compromised and replacement of entire femoral head is necessary

SLIDE 13: Types of hip replacements
-Xray of total hip with components.
-Total hip Acetabular portion of patient is replaced ICD-9-CM 81.51. 
-Xray of partial hip (bipolar) and 1 piece endoprosthesis
-Partial hips Acetabular portion of patient stays intact ICD-9-CM 81.52
-Xray of resurfacing hip.
-Resurfacing hip Femoral component replaces less of patient femur. Acetabular portion of patient is replaced.ICD-9-CM 00.85

SLIDE 14: Partial hip vs. Total hip
-Partial hip
--Articulation with acetabular area is smooth and maintains native acetabulum.
--New femoral head rotates within acetabulum and articulates with native cartilage
-Total hip
--Native acetabulum is removed and replaced with a cup. Articulation is between the insert and femoral head.
--Acetabulum is reamed out during procedure and cup is fixed to pelvi

SLIDE 15: Demographics of joint replacements
-Total hips are younger patients with arthritis (OA), generally treated electively. 90% have OA, and 45% less than 65 yrs.
-Partial hips are older patients with fractures, often treated on an emergency basis. 93% have fracture, 92% over 65 yrs.
-Source: Orthopedic Network News

SLIDE 16: Conclusion
-Total hip and partial hip replacement patients have much different demographics, treatment devices, and outcomes
-Reasons for failure of these devices are very different
-Registries rely on coding of total hips and partial hips to identify patients to review
-Essential to provide mechanism to differentiate the cases in ICD-10-PCS

SLIDE 17: Partial Hip Replacement
-Create new device code for endofemoral replacement
--Differentiates partial hip from total hip replacements when the coder looks at the “replacement of hip joint” table
--Allows appropriate identification and tracking of these cases so that both patient populations can benefit from registry information.

SLIDE 18: (Repeat of slide 13)
- Types of hip replacements
-Xray of total hip with components.
-Total hip Acetabular portion of patient is replaced ICD-9-CM 81.51. 
-Xray of partial hip (bipolar) and 1 piece endoprosthesis
-Partial hips Acetabular portion of patient stays intact ICD-9-CM 81.52
-Xray of resurfacing hip.
-Resurfacing hip Femoral component replaces less of patient femur. Acetabular portion of patient is replaced.ICD-9-CM 00.85

SLIDE 19: Resurfacing
-Add “Resurfacing Device” to 0SR9/B root operation and remove from 0SU9/B root operation
--Emphasize that it is a replacement for the joint, not a supplement
--Resurfacing is really just one type of hip replacement rather than a different kind of procedure
---Similar surgical technique, patient population, recovery, and elective nature as THA
---Need to identify and monitor separately from THA as failure mechanisms are different
	
SLIDE 20: Knee Replacements
-Unicondylar knee
-Patellofemoral joint replacements

SLIDE 21: Types of knee replacements
-Total knee Both condyles of knee are replaced ICD-9-CM 81.54
-Unicondylar knee Either lateral or medial condyle replaced ICD-9-CM 81.54
-Patellofemoral joint replacement (PFJ) Femoral component placed in trochlear groove, patella resurfaced ICD-9-CM 81.54


SLIDE 22: Recommendations 
-Create separate device code under 0SRC/D for unicondylar knee (uni knee) 
-Create separate device code under 0SRC/D for patellofemoral joint (PFJ) replacement
-Allows differentiation of specific surgeries
-Technology developed in the 1980s for unicompartmental knee replacement
-Overdue in ICD-9-CM

SLIDE 23: Revision Surgery 
-Adding body parts to table OSP
-Hip and knee arthroplasty index revisions

SLIDE 24: Revision procedures for joint replacements
-Revision to hip and knee replacements
--Causes due to “wear and tear”, mechanical failure, infection
--Revision means “removal and replacement”
---Hip revision ICD-9-CM codes:
----00.70  Femur and acetabulum
----00.71  Acetabular component
----00.72  Femoral component
----00.73  Acetabular head/liner only 
---Knee revision ICD-9-CM codes:
----00.80  Femur + tibia
----00.81  Tibial component only
----00.82  Femoral component only
----00.83  Patellar component
----00.84  Tibial insert (liner)
--Infection may involve “two-stage” revision
---Stage 1 removes implant and replaces with antibiotic eluting device
----ICD-9-CM 80.05/80.06 Removal of prosthesis from hip or knee
----ICD-9-CM 84.56 Insertion of spacer
---Stage 2 removes antibiotic spacer and replaces with “revision” system
----ICD9-CM 84.57 Removal of spacer
----ICD-9-CM 00.80 Revision knee replacement

SLIDE 25: Definition of Revision
-ICD-10-PCS Table OSW
--“Revision: Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device”	
-Orthopaedic definition
--Revision is most often removing a malfunctioning or infected device and replacing it with a new one
---Loss of fixation, infection
--Any repeat surgery involving an implant
-ICD-10-PCS definition implies that the device is repositioned or a portion is changed, but this is not often the case
--Head/liner exchange in total hip replacement

SLIDE 26: Some Indications for revising hips
-Dislocation 
-Mechanical failure
-Osteolysis (loosening)

SLIDE 27: Some Indications for revising knees
-Broken tibial insert
-Infection
--ICD-9-CM Stage 1:
---80.06 Prosthesis removial
---84.56 Insertion of spacer
--ICD-9-CM Stage 2:
---84.57 Removal of spacer
---00.80 Insertion of revision device

SLIDE 28: Recommendations
-Add femoral, tibial, acetabular body parts to 0SP root operation (Removal of prosthesis from lower joints)
-Create new body part for patellar surface

SLIDE 29: Hip and Knee Procedure Index Revision
-Add appropriate index guidance for revision hip and knee procedures
--“Revision” for joint replacements virtually always means remove and replace
--Remove and replace are separate procedures in ICD-10-PCS
--Redefinition of “Revision” may lead to inappropriate coding  and reporting of procedures by coders

SLIDE 30: Recommendations 
-Change name of device code for “Liner” to “Bearing surface”
--Liner is listed at alternative term for tibial insert
--Most references for liner are acetabular liner
--“Bearing surface” more accurately reflects common usage in orthopedics

SLIDE 31: Summary of recommendations
-Add new device code for partial hips (endo-femoral device)
-Add resurfacing device code to 0SR9/B root operation
-Add new device code for unicondylar knee
-Add new device code for patellofemoral joint replacement
-Add body parts for hips and knees to 0SP root operation for removal of prostheses; create new body part for patellar surface
-Modify index entries for hip/knee revisions to ensure proper coding
-Change name of device code from “Liner” to “Bearing surface”

SLIDE 21: Thank You