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Z96.642
ICD-10-CM
Left Hip Replacement

Find comprehensive information on Left Hip Replacement including clinical documentation, medical coding, ICD-10-CM codes (Z96.641, Z96.642), CPT codes (27130, 27134, 27137, 27138), postoperative care, and rehabilitation. This resource helps healthcare professionals ensure accurate coding and documentation for left total hip arthroplasty, partial hip replacement, hip resurfacing, and revision procedures. Learn about diagnosis, treatment, and long-term management of left hip replacement.

Also known as

Left Total Hip Arthroplasty
Left Hip Arthroplasty

Diagnosis Snapshot

Key Facts
  • Definition : Surgical replacement of a damaged hip joint with an artificial one.
  • Clinical Signs : Hip pain, stiffness, limited range of motion, difficulty walking.
  • Common Settings : Hospital operating room, outpatient surgery center, rehabilitation facility.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z96.642 Coding
Z96.64-

Presence of left artificial hip joint

Indicates a patient has a left artificial hip joint.

0SR90JZ

Revision of left total hip replacemen

Codes for revision procedures on a left total hip replacement.

0SRD0JZ

Removal of left total hip replaceme

Codes for removal of a left total hip replacement.

T84.51XA

Infection & inflammatory reaction

Complications, such as infection, following a left hip replacement.

Code-Specific Guidance

Decision Tree for

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

Is this a total hip replacement?

  • Yes

    Routine or subsequent encounter?

  • No

    Partial or revision?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left Hip Replacement
Left Hip Osteoarthritis
Left Femoral Neck Fracture

Documentation Best Practices

Documentation Checklist
  • Left hip replacement documentation
  • ICD-10-PCS code for total hip arthroplasty
  • Laterality: Confirm left hip
  • Preoperative diagnosis: Specify reason
  • Implant details: Type and components

Coding and Audit Risks

Common Risks
  • Laterality Coding Error

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

  • Approach Documentation

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

  • Revision vs. Primary

    Insufficient documentation to distinguish a revision surgery from a primary hip replacement, affecting coding and payment.

Mitigation Tips

Best Practices
  • Accurate ICD-10-PCS code capture for hip replacement: Optimize reimbursement.
  • Specific laterality documentation (left hip) improves coding accuracy.
  • Detailed operative report vital for proper DRG assignment, compliant billing.
  • Timely CDI queries clarify documentation, minimize denials, ensure compliance.
  • Prophylactic antibiotic details crucial for surgical site infection tracking compliance.

Clinical Decision Support

Checklist
  • Confirm osteoarthritis diagnosis code (e.g., M16)
  • Verify failed conservative treatment documented
  • Check radiographic evidence of hip joint damage
  • Assess patient surgical risks and comorbidities
  • Document informed consent and pre-op checklist

Reimbursement and Quality Metrics

Impact Summary
  • Left Hip Replacement 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 readmission rate affect value-based payments.
  • Timely and complete documentation is crucial for optimizing left hip replacement reimbursement and avoiding denials.
  • Proper coding for complications like dislocation or infection maximizes reimbursement and accurately reflects quality.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code primary THR, ICD-10-PCS
  • Verify laterality: Left hip
  • Document implant details
  • Check 7th character for encounter
  • Query physician if unclear

Documentation Templates

Patient presents with complaints of chronic left hip pain, stiffness, and limited range of motion consistent with osteoarthritis.  Symptoms include difficulty walking, impaired mobility, and pain exacerbated by weight-bearing activities.  On physical examination, decreased left hip flexion, internal rotation, and abduction were noted, along with crepitus on movement.  Radiographic imaging of the left hip revealed joint space narrowing, osteophyte formation, and subchondral sclerosis, confirming the diagnosis of osteoarthritis.  Conservative management including physical therapy, NSAIDs, and activity modification has provided insufficient relief.  The patient is scheduled for a total left hip arthroplasty (THA), also known as left hip replacement surgery, to alleviate pain, improve function, and restore mobility.  Risks and benefits of the procedure, including potential complications such as infection, dislocation, and deep vein thrombosis, were discussed with the patient, and informed consent was obtained.  Preoperative clearance and optimization of medical comorbidities are underway.  Postoperative care will include pain management, physical therapy, and anticoagulation therapy as indicated.  ICD-10 code M16.11 (Primary osteoarthritis, left hip) and CPT code 27130 (Total hip arthroplasty) are relevant for this case.  Keywords: Left hip pain, hip osteoarthritis, total hip arthroplasty, THA, hip replacement surgery, joint pain, limited mobility, hip replacement recovery, postoperative care, ICD-10 M16.11, CPT 27130, physical therapy, osteoarthritis treatment, hip surgery.