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Z96.642
ICD-10-CM
Left Hip Arthroplasty

Find comprehensive information on Left Hip Arthroplasty diagnosis, including clinical documentation requirements, medical coding guidelines, and healthcare resources. This page covers ICD-10-CM codes for Left Hip Arthroplasty, postoperative care, and relevant medical terminology for accurate reporting and optimized reimbursement. Explore details on total hip replacement, partial hip replacement, hip resurfacing, and revision arthroplasty of the left hip. Learn about diagnosis criteria, treatment options, and best practices for documenting Left Hip Arthroplasty in medical records.

Also known as

Left Total Hip Replacement
Left Hip Joint Replacement

Diagnosis Snapshot

Key Facts
  • Definition : Surgical replacement of the hip joint with an artificial prosthesis.
  • Clinical Signs : Hip pain, stiffness, limited range of motion, difficulty walking.
  • Common Settings : Hospitals, outpatient surgical centers, orthopedic clinics.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z96.642 Coding
0SR90ZZ

Replacement of left hip joint

Insertion of artificial hip joint in left leg.

0SRB0ZZ

Revision of left hip joint

Correction or replacement of existing left hip prosthesis.

T84.01XA

Mechanical complication of left hip

Problem with left hip prosthesis function or placement.

Z96.642

Presence of left artificial hip joint

Indicates a left hip replacement has already been performed.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is this a total left hip replacement?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left Hip Arthroplasty
Left Hip Revision Arthroplasty
Periprosthetic Fracture Left Hip

Documentation Best Practices

Documentation Checklist
  • Laterality (left hip) documented
  • Reason for arthroplasty specified
  • Type of arthroplasty (total/partial) noted
  • Surgical approach documented
  • Implants/components used detailed

Coding and Audit Risks

Common Risks
  • Laterality Coding Error

    Incorrectly coding the right hip instead of the left, or not specifying laterality, leading to claim rejections or inaccurate data.

  • Approach Documentation

    Missing documentation of the surgical approach (anterior, posterior, etc.) impacting accurate code assignment and reimbursement.

  • Revision vs. Primary

    Failure to distinguish between primary and revision arthroplasty, resulting in incorrect coding and potential compliance issues.

Mitigation Tips

Best Practices
  • Accurate ICD-10-PCS code for Left Hip Arthroplasty: Document approach, components
  • Specific laterality (left hip) key for correct coding and reimbursement
  • Clear documentation of implant type crucial for proper medical device tracking
  • Post-op complications: Detailed descriptions needed for accurate coding, quality metrics
  • Consistent, precise clinical documentation improves data integrity, reduces compliance risks

Clinical Decision Support

Checklist
  • Verify pre-op diagnosis: Osteoarthritis, fracture, or other hip pathology
  • Confirm radiographic evidence of hip joint damage
  • Check prior conservative treatments documented (e.g., PT, injections)
  • Patient informed consent obtained and documented

Reimbursement and Quality Metrics

Impact Summary
  • Left Hip Arthroplasty reimbursement hinges on accurate ICD-10-PCS and CPT coding, impacting DRG assignment and payment.
  • Quality metrics like surgical site infection rate, length of stay, and functional improvement affect value-based payments for Left Hip Arthroplasty.
  • Timely and accurate coding of Left Hip Arthroplasty procedures minimizes claim denials and optimizes revenue cycle management.
  • Hospital reporting on Left Hip Arthroplasty outcomes using standardized codes enhances transparency and quality improvement efforts.

Streamline Your Medical Coding

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Frequently Asked Questions

Common Questions and Answers

Q: What are the evidence-based postoperative pain management protocols for minimizing opioid use after left hip arthroplasty?

A: Effective postoperative pain management after left hip arthroplasty is crucial for optimizing patient recovery while minimizing opioid reliance. Multimodal analgesia protocols are the current gold standard, combining non-opioid analgesics (NSAIDs, acetaminophen), regional anesthesia (femoral nerve block, fascia iliaca block), and local anesthetic infiltration. Liposomal bupivacaine can provide extended pain relief. Cryotherapy and early mobilization also play a role. Explore how a standardized protocol incorporating these elements can reduce opioid requirements and improve patient outcomes. Consider implementing patient-specific pain goals and regularly assessing pain levels using validated scales like the Numerical Rating Scale. Learn more about Enhanced Recovery After Surgery (ERAS) protocols which incorporate many of these principles.

Q: How do I differentiate between normal postoperative swelling and signs of infection following left hip arthroplasty, and what immediate steps should I take?

A: Differentiating normal postoperative swelling from infection after left hip arthroplasty requires careful clinical assessment. While some swelling and erythema are expected, signs suggestive of infection include excessive swelling extending beyond the surgical site, persistent increasing pain despite analgesics, purulent drainage, fever, chills, and elevated inflammatory markers (CRP, ESR). If infection is suspected, prompt action is critical. Consider obtaining deep tissue cultures and aspirates, consulting with an infectious disease specialist, and initiating empiric antibiotic therapy based on suspected pathogens. Explore how early detection and aggressive management of periprosthetic joint infection can improve long-term outcomes. Learn more about evidence-based diagnostic criteria and treatment algorithms for periprosthetic joint infections.

Quick Tips

Practical Coding Tips
  • Code primary THA, not hemiarthroplasty
  • Verify laterality: Left hip crucial
  • Document implant details for specificity
  • Check 7th character for encounter type
  • Consider comorbidities for accurate coding

Documentation Templates

Patient presents with complaints of chronic left hip pain, stiffness, and functional limitation, consistent with osteoarthritis.  Symptoms include significant pain with weight-bearing activities, reduced range of motion impacting mobility, and night pain interfering with sleep.  The patient reports a history of conservative management including physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroid injections, with limited or temporary relief.  Physical examination reveals decreased left hip flexion, internal rotation, and abduction, as well as palpable crepitus and tenderness upon palpation.  Radiographic imaging confirms advanced osteoarthritis of the left hip joint, characterized by joint space narrowing, osteophyte formation, and subchondral sclerosis.  After discussing the risks and benefits of surgical intervention, the patient elected to proceed with left total hip arthroplasty.  The procedure will involve the replacement of the damaged articular surfaces of the left hip joint with prosthetic components.  Postoperative care will include pain management, physical therapy, and close monitoring for complications such as infection, dislocation, and deep vein thrombosis.  ICD-10 code M16.11, left primary osteoarthritis, hip, will be utilized for diagnosis coding, along with relevant procedure codes for the arthroplasty. This documentation supports medical necessity for left hip arthroplasty as a treatment for debilitating left hip osteoarthritis.