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Z96.642
ICD-10-CM
Left Hip Surgery

Find comprehensive information on Left Hip Surgery diagnosis, including clinical documentation, medical coding (ICD-10, CPT), postoperative care, and rehabilitation. Learn about common left hip procedures, such as hip replacement, arthroscopy, and fracture repair. Explore resources for healthcare professionals, including coding guidelines and best practices for documenting left hip surgery. Understand the different types of left hip surgeries, potential complications, and recovery timelines. This resource provides valuable insights for accurate and efficient clinical documentation and medical coding related to Left Hip Surgery.

Also known as

Left Hip Replacement
Left Total Hip Arthroplasty

Diagnosis Snapshot

Key Facts
  • Definition : Surgical repair or replacement of the left hip joint.
  • Clinical Signs : Left hip pain, stiffness, limited range of motion, limping, groin pain.
  • Common Settings : Hospitals, outpatient surgical centers, orthopedic clinics.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z96.642 Coding
S72.0-S72.9

Fracture of femur

Covers various left hip fractures potentially needing surgery.

M24.55

Pain in left hip

Hip pain may indicate underlying issues requiring surgical intervention.

M16-M19

Coxarthrosis

Osteoarthritis of the hip can necessitate surgical procedures like replacements.

Z96.64

Presence of left artificial hip joint

Indicates prior hip surgery and may relate to complications/revisions.

Code-Specific Guidance

Decision Tree for

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

Is this an initial encounter for the surgery?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left Hip Replacement
Left Hip Fracture
Left Hip Arthroscopy

Documentation Best Practices

Documentation Checklist
  • Left hip surgery: ICD-10, CPT codes documented
  • Pre-op diagnosis, laterality specified
  • Surgical approach, technique detailed
  • Implants, devices, allografts recorded
  • Post-op diagnosis, complications noted

Coding and Audit Risks

Common Risks
  • Unspecified Approach

    Coding lacks specificity for anterior, posterior, lateral, or other approach, impacting DRG assignment and reimbursement.

  • Laterality Missing

    Documentation fails to clearly indicate left hip, potentially leading to incorrect coding or medical necessity denials.

  • Implant Not Coded

    Missing codes for implanted devices can result in lost revenue and inaccurate reporting for quality metrics.

Mitigation Tips

Best Practices
  • Code left hip surgery with ICD-10-PCS, ensure laterality
  • Document reason, approach, implant details for accurate coding
  • Query physician for clarity if documentation is unclear
  • Regularly audit left hip surgery coding for compliance
  • Educate staff on proper left hip surgery documentation

Clinical Decision Support

Checklist
  • Confirm left hip imaging reports (X-ray, MRI, CT)
  • Verify left hip physical exam findings documented
  • Check pre-op checklist for left hip procedure
  • Review patient consent for left hip surgery

Reimbursement and Quality Metrics

Impact Summary
  • Left Hip Surgery reimbursement hinges on accurate ICD-10 PCS and CPT coding for optimal payment.
  • Quality metrics like surgical site infection rate, length of stay, and readmission rate impact value-based payments.
  • Coding accuracy directly affects hospital reporting for Left Hip Surgery, impacting quality scores and reimbursement.
  • Proper documentation and coding prevent claim denials and optimize Left Hip Surgery reimbursement.

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.

Frequently Asked Questions

Common Questions and Answers

Q: What are the most effective evidence-based post-operative rehabilitation protocols for left hip surgery patients with pre-existing osteoarthritis?

A: Post-operative rehabilitation for left hip surgery patients with pre-existing osteoarthritis requires a tailored approach considering the specific surgical procedure (e.g., total hip arthroplasty, hip resurfacing) and the severity of the pre-existing osteoarthritis. Evidence-based protocols generally emphasize early mobilization, progressive weight-bearing as tolerated, and a combination of strengthening and range-of-motion exercises. A focus on pain management is crucial, often involving a multimodal approach with medications, cryotherapy, and other modalities. Specific exercises may include ankle pumps, quadriceps sets, glute bridges, and assisted hip flexion/extension. The rehabilitation plan should be individualized based on patient progress and functional goals, with regular monitoring by a physical therapist. Consider implementing a phased approach to rehabilitation, starting with basic mobility and progressing to more challenging activities as the patient recovers. Explore how our platform can help streamline the creation of personalized post-operative rehabilitation plans. Learn more about the latest research on osteoarthritis management in the context of hip surgery.

Q: How can clinicians differentiate between referred pain from the lumbar spine and true left hip pain when diagnosing the need for left hip surgery?

A: Differentiating between referred lumbar spine pain and true left hip pain can be challenging but is essential for accurate diagnosis and treatment planning for potential left hip surgery. A thorough clinical examination, including a detailed history and physical assessment, is critical. Key differentiating factors include the location of pain, range of motion limitations, and provocative tests. True hip pain is typically localized to the groin, buttock, or anterior thigh, while referred lumbar pain can radiate down the leg. Assessing hip range of motion in flexion, extension, abduction, adduction, internal and external rotation can help identify specific hip joint involvement. Special tests such as the FABER test (flexion, abduction, external rotation) and the FADIR test (flexion, adduction, internal rotation) can further isolate hip pathology. Imaging studies, such as X-rays, MRI, or CT scans, may be necessary to confirm the diagnosis and rule out other conditions. Consider implementing a standardized assessment protocol to ensure consistent evaluation of patients presenting with hip pain. Explore how advanced imaging techniques can aid in the diagnostic process for differentiating hip and lumbar spine pathologies.

Quick Tips

Practical Coding Tips
  • Code laterality: Left hip
  • Check approach: Anterior, posterior
  • Specify prosthesis, if any
  • Document complications
  • ICD-10: Verify diagnosis code

Documentation Templates

Patient presents with complaints of left hip pain, stiffness, and limited range of motion, consistent with a clinical presentation of osteoarthritis, potentially requiring left hip surgery.  Symptoms include difficulty with ambulation, weight-bearing activities, and activities of daily living.  On physical examination, decreased range of motion in the left hip was noted, along with tenderness to palpation and crepitus.  Radiographic imaging of the left hip reveals joint space narrowing, osteophyte formation, and subchondral sclerosis, confirming the diagnosis of osteoarthritis.  The patient's medical history includes hypertension and hyperlipidemia, managed with appropriate medications.  Surgical intervention, such as total hip arthroplasty or hip resurfacing, is being considered as a treatment option to alleviate pain and improve functionality.  Risks and benefits of the procedure, including potential complications such as infection, dislocation, and deep vein thrombosis, were discussed with the patient.  Conservative management options including physical therapy, pain medication, and assistive devices were also reviewed.  The patient will follow up for further evaluation and surgical scheduling, pending insurance authorization for left hip surgery.  ICD-10 code M16.11, left primary coxarthrosis, and CPT codes for the specific surgical procedure, such as 27130 for total hip arthroplasty, will be utilized for medical coding and billing purposes.