The following article was published in Orthopedic Network News (ONN), Trauma Update, Volume 13, Number 2, April 2002. To sign up for all ONN editions in print and online, plus all archives, click here: ONN Subscription
Hip fractures, the most commonly treated fracture in hospitals, are recognized as a major public health problem in the United States. Patients with hip fractures are most often elderly women. According to the AAOS web-site, only 25 percent of hip fracture patients will make a full recovery; 40 percent will require nursing home care; 50 percent will need a cane or walker; and 24 percent of those over age 50 will die within 12 months.
Almost all patients with a hip fracture have a surgical procedure. This may be the implantation of cannulated screws, a compression hip screw, total or partial hip replacements, or intramedullary nail, depending on the location of the fracture, age and quality of the patient’s bone, the expectations for rehabilitation, and the desires of the surgeon. In general, femoral neck fractures may receive the most different types of hardware, depending on the factors outlined above.
Since hip fractures are most frequent among Medicare-aged women, the ICD-9-CM coding and DRG payment system are extremely important to the classification, assignment, and payment for these cases. Patients with a total hip are assigned ICD-9-CM code 81.51, bipolar, unipolar, and endoprosthesis procedures are assigned procedure code 81.52, even though the cost between the devices differ significantly. Finally, hip nails, compression hip screws, recon nails, and cannulated hip screws are all assigned to procedure 78.55, 79.15, 79.35 or 79.55, depending on whether closed reduction is performed or not. In general, the most frequently assigned procedure is 79.35, open reduction and internal fixation of the femur.
The DRG assigned to these cases is fairly straightforward. If the patient has a total hip or partial hip, they are assigned to DRG 209, Joint replacement, with a payment of about $9,000, depending on the hospital’s location. If the patient receives an internal fixation device, they are assigned to DRG 210, lower extremity operation, except total joint with complications/comorbid conditions, and a payment of about $8,000. If there are no complications or comorbid conditions, they are assigned to DRG 211, with a payment of about $5,500.
The way that the DRG payment system works is that if the hospital spends less to treat these patients than their Medicare payment they may retain the difference, but if it costs more to treat these patients, the hospital must absorb the cost.