Reimbursement for Hip Fractures: The Impact of Varied Current Procedural Terminology Coding Using Relative Value Units

Perioperative Outcomes of Intramedullary Nail vs Hemiarthroplasty vs Total Hip Arthroplasty for Intertrochanteric Fracture: An Analysis of 31,519 Cases

Background

The purpose of this study is to compare 30-day perioperative outcomes following treatment of intertrochanteric (IT) fractures with intramedullary nail (IMN), total hip arthroplasty (THA), or hemiarthroplasty (HA).

Methods

Using the National Surgical Quality Improvement Program database, we conducted a retrospective cohort study of patients who had sustained an IT fracture treated with primary IMN, THA, or HA between 2017 and 2020. International Classification of Diseases, 10th Revision codes S72.141-S72.146, subtypes A through C, were used to identify eligible patients and were cross-referenced to primary Current Procedural Terminology codes, used to identify the following procedure types: 27245: IMN; 27130: THA; and 27236: HA. Revision cases and patients who underwent arthroplasty for osteoarthritis were excluded. Outcomes of interest included reoperation, readmission, operative time, length of stay, and major and minor complications. Multivariate regression was used to evaluate differences in postoperative outcomes between groups.

Results

There were 29,809 IT fractures treated with IMN (94.6%), 1493 treated with HA (4.7%), and 217 treated with THA (0.70%). There was a statistically significant increase in 30-day reoperation rates (adjusted odds ratio [aOR] = 1.99 [95% confidence interval = 1.51, 2.63], P < .001) when combining all arthroplasty patients compared to IMN. There was no statistically significant difference in the overall complication rate between IMN (13.58%) and HA (14.60%, aOR = 1.09, P = .315) or THA (11.98%, aOR = 1.00, P = .998). When compared to IMN (0.12%), there was a statistically significantly decreased need for transfusion in the HA group (aOR = 0.71 [95% confidence interval = 0.61, 0.80], P < .001).

Conclusions

Primary HA is associated with an increased 30-day reoperation rate and decreased need for blood transfusion, but there were no other significant differences in postoperative morbidity identified among IMN, THA, and HA in the treatment of IT fractures. Given the challenges and inferior outcomes associated with conversion arthroplasty, the lack of significant difference in morbidity between the 3 groups suggests that primary arthroplasty may be a safe and viable treatment option in selected patients with IT fractures. Comparative studies with longer clinical follow-up will be necessary to establish the appropriate indications and further evaluate the clinical outcomes of primary arthroplasty in the treatment of IT fractures.

Reverse shoulder arthroplasty for proximal humerus fractures and reverse shoulder arthroplasty for elective indications should have separate Current Procedural Terminology (CPT) codes

BACKGROUND

Reverse shoulder arthroplasty (RSA) for fracture currently shares a single Current Procedural Terminology (CPT) code with RSA for arthropathy despite potential differences in patient factors, procedural demands, postoperative care and needs, and overall hospital systems' resource utilization. We hypothesize that patients indicated for RSA for fracture will have greater medical complexity, require longer operative duration, have higher complication rates, demonstrate inferior functional outcomes, and require greater health care cost expenditures compared to a cohort undergoing RSA for rotator cuff arthropathy.

METHODS

A total of 383 RSAs were retrospectively reviewed from January 2011 to December 2020. Demographics, comorbidities, operative time, financial charge and cost data, length of stay (LOS), discharge disposition, and all-cause revisions were assessed. Visual analog scale (VAS) pain score and active range of motion (AROM) were evaluated at 2, 6, and 12 months postoperatively.

RESULTS

After exclusions, 197 total RSAs were included, with 28 for fracture and 169 for arthropathy indications. RSA operative time was longer for fractures with an average of 143.2 ± 33.7 minutes compared with 108.2 ± 33.9 minutes for arthropathy (P = .001). Average cost per patient for RSA for proximal humerus fracture was $2489 greater than the cost for RSA for elective indications; however, no statistically significant difference was noted between average costs (P = .126). LOS was longer for RSA for fracture compared to arthropathy, with a mean of 4.0 ± 3.6 days vs. 1.8 ± 2.3 days (P = .004). The fracture group was 3.6 times more likely to be discharged to a skilled nursing facility or inpatient rehabilitation (32% vs. 9%, P = .002). Early and late all-cause revisions were similar between groups. Differences in postoperative AROM for fracture vs. arthropathy were significant for active forward flexion at 2 months (95.5° ± 36.7° vs. 117.0° ± 32.3°, P = .020) and 6 months (110.9° ± 35.2° vs. 129.2° ± 28.3°, P = .020) as well as active adducted external rotation at 6 months (20.0° ± 20.9° vs. 33.1° ± 12.3°, P = .007) and at 12 months (23.3° ± 18.1° vs. 34.5° ± 13.8°, P = .012). No difference in VAS pain scores were noted between fracture and arthropathy groups at any time point.

DISCUSSION

RSA for fractures vs. arthropathy have substantial differences in patient characteristics, surgical complexity, and hospital resource utilization. This is of importance given the currently available CPT code does not differentiate indications for RSA, especially if intending to accurately document the surgical care delivered.

Ranking the Orthopedic Procedures With the Highest Morbidity and Mortality

BACKGROUND

Musculoskeletal conditions currently affect more than one-third of the US population and orthopedic procedures play a pivotal role in managing them. Like any invasive intervention, these carry a wide spectrum of risk, necessitating a comprehensive understanding of the associated morbidity and mortality. This study sought to provide a global perspective of the risks and complications associated with these procedures to establish an easy to understand risk stratification tool for both patients and providers.

MATERIALS AND METHODS

Current Procedural Terminology codes associated with orthopedic surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2018 to 2020. Each code was associated with its rate of 30-day mortality as well as any adverse event (AAE) and then ranked for descriptive analysis.

RESULTS

In total, there were 698,549 patients who underwent orthopedic procedures associated with 94 CPT codes with at least 1 morbidity event and 144 CPT codes with at least 1 AAE. The CPT code associated with the highest mortality was 27590 or above knee amputation. The CPT code associated with the highest rate of AAE was 27507 or open treatment of femoral shaft fracture with plate and screws.

CONCLUSION

This is the first study to compare the rates of morbidity and mortality in all patients with orthopedic procedures. There was a strong bias toward increased risk associated with lower extremity surgery and surgery most often performed in the geriatric population. [Orthopedics. 202x;4x(x):xx-xx.].

Association between operative duration and adverse outcomes after hip fracture surgery: A NSQIP matched cohort study

BACKGROUND

Prolonged operative duration is an independent risk factor for surgical complications in numerous subspecialties. However, associations between adverse events and operative duration of hip fracture fixation in older adults have not been well-quantified. This study aims to determine if prolonged operative duration of hip fracture surgery is related to adverse outcomes. We hypothesized that patients with high operative durations experience greater rates of 30-day complications.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively reviewed to identify older adults (55 years and above) who underwent hip fracture fixation between 2015-2019. Prolonged operative duration was defined as >75th percentile, and cases were matched using propensity scores based on demographic, surgical, and comorbidity factors. Univariate differences in adverse events (including readmission, reoperation, mortality, and organ-system complications) were analyzed. Multivariable mixed-effects logistic regression analyses were completed for statistically significant events.

RESULTS

A total of 8827 case-control pairs were identified for comparison. Rates of superficial surgical site infection (SSI) (p= 0.022), any SSI (p= 0.032), and any complication (p < 0.001) were elevated in those with prolonged surgical duration in univariate analyses. In multivariable models, prolonged operative time was associated with superficial SSI (OR 1.50, p= 0.019), any SSI (OR 1.35; p= 0.029) and any complication (OR 1.58; p < 0.001). In subgroup analyses, all findings persisted for IMN with operative time associated with superficial SSI (OR 1.98, p= 0.012), any SSI (OR 1.71; p= 0.019), and any complication (OR 1.84; p < 0.001). Operative time was associated only with any complication for hemiarthroplasty/internal fixation and sliding hip screw (OR 1.27 and 1.89, respectively; p < 0.001).

CONCLUSION

Our study demonstrates that duration of surgery is an independent risk factor for superficial SSI, any SSI, and any complication. Notably, our findings suggest that high operative durations may be most concerning for SSIs in IMN fixation, which is currently the most common choice for hip fracture fixation in the US. However, the rate of any complication is significantly elevated when surgical duration is prolonged, regardless of surgery type.

Complications following total hip arthroplasty and hemiarthroplasty for femoral neck fractures in patients with a history of lumbar spinal fusion

INTRODUCTION

The purpose of this study was to examine whether previous lumbar spinal fusion (LSF) was an independent risk factor for complications in patients undergoing total hip arthroplasty (THA) or hemiarthroplasty for displaced femoral neck fractures.

METHODS AND MATERIALS

An administrative database was queried from 2010 to Q2 of 2019 to analyze and compare complications in patients undergoing either THA or hemiarthroplasty for femoral neck fracture with a history of LSF versus no history of LSF. Joint complications including periprosthetic fracture, prosthetic joint infection (PJI), prosthetic joint dislocation (PJD), aseptic loosening, and prosthetic revision were examined at 90 days and 1 year post-operatively.

RESULTS

In the THA cohort, patients with prior LSF had significantly higher likelihood of aseptic loosening at 90 days and 1 year post-operatively in comparison to those without prior LSF (90-day: OR 2.22; 1-year: OR 1.95). Patients in the hemiarthroplasty cohort with prior LSF had significantly higher likelihood of PJI (90-day: OR 2.18; 1-year: OR 2.37), aseptic loosening (90-day: OR 3.42; 1-year: OR 4.68), and prosthetic revision (90-day: OR 2.27; 1-year: OR 2.25) in both the 90-day and 1-year postoperative period in comparison to those without prior LSF. Additionally, for the same cohort, periprosthetic fracture (1-year: OR 2.32) and PJD (1-year: OR 2.31) were significantly higher at 1-year postoperative.

CONCLUSION

Presence of LSF was found to be an independent risk factor for increased joint complications in patients undergoing either a THA or hemiarthroplasty for displaced femoral neck fractures.

The accuracy of hip fracture data entered into the national surgical quality improvement program (NSQIP) database

PURPOSE

Internal validation studies of National Surgical Quality Improvement Program (NSQIP) registry data have reported potential inaccuracies. The purpose of this study was to determine the accuracy of hip fracture CPT codes and complications entered into NSQIP for a single participating center.

METHODS

A retrospective study identified patients with a hip fracture CPT code from NSQIP data at a single institution over a two-year period. CPT codes included 27235 (percutaneous fixation of femoral neck fracture (Perc FNFX)), 27236 (open treatment of femoral neck fracture, internal fixation/prosthetic replacement (Open FNFX)), 27244 (open treatment of inter/peri/subtrochanteric femoral fracture with plate (Plate ITFX)), 27245 (treatment of inter/peri/subtrochanteric femoral fracture, with intramedullary implant (IMN ITFX)), and 27125 (hemiarthroplasty (HA)). The institutional medical record was reviewed to determine the accuracy of CPT code and 30-day complication data entered into the registry.

RESULT

12.8% (n = 20/156) of patients had an inaccurate CPT code. The proportion of inaccurate CPT codes varied significantly by procedure: Plate ITFX (76.9%), Open FNFX (13.8%), IMN ITFX (7.0%), and HA (0%) (p < 0.0001). A total of 82 complications were identified in 66 patients via the medical record. 43.9% (n = 36/82) of these complications were not documented in the NSQIP data. The proportion of missing complications varied significantly by type: renal (100%), UTI (53.8%), infection (50%), bleeding (30%), death (25%), respiratory (25%), cardiac (0%), stroke (0%), and VTE (0%) (p < 0.0001).

CONCLUSION

Hip fracture CPT codes and 30-day complication data entered into the NSQIP registry were frequently inaccurate. Studies incorporating NSQIP data should acknowledge these potential limitations of the registry, and future research to validate NSQIP orthopedic data across procedures and institutions is necessary.

LEVEL OF EVIDENCE

LEVEL III: Diagnostic study.

Complication Rates of Hemiarthroplasty Conversion to Total Hip Arthroplasty Versus Primary Total Hip Arthroplasty

Background

One of the most common surgical options for treatment of a femoral neck fracture is hemiarthroplasty (HA). However, progression of arthritis or pain can necessitate conversion to total hip arthroplasty (THA). While conversion to a THA is a viable option, it does carry multiple risks. The purpose of this study was to identify whether performing conversion from HA to THA carries an increased risk of post-operative joint complications when compared to elective THA.

Methods

An administrative claims database was queried to identify patients who underwent conversion from a HA to a THA. Incidences of prosthetic dislocation, prosthetic joint infection (PJI), periprosthetic fracture, aseptic loosening, and revision were collected and compared to elective primary THA with multivariable logistic regression.

Results

Patients undergoing conversion THA had significantly higher risks of all joint complications examined at both 1 and 2 years after surgery. These included prosthetic dislocation (1-year: OR 2.95; 2 years: OR 3.77), PJI (1-year: OR 1.38; 2 years: OR 2.13), periprosthetic fracture (1-year: OR 2.95; 2 years: OR 3.75), aseptic loosening (1-year: OR 6.86; 2 years: OR 7.70), and revision (1-year: OR 3.65; 2 years: OR 6.73).

Conclusion

Performing conversion arthroplasty from HA to THA is associated with an increased risk of multiple joint complications in both the short and mid-term follow-up period. Surgeons should consider these complications when indicating HA for femoral neck fractures and elective conversion arthroplasty.