Welcome to our webinar on hip fractures. My name is Maria Penrose. I'm a trauma data coordinator at Nationwide Children's Hospital in Columbus, Ohio. It's a level one pediatric facility. And today I'm gonna introduce our speakers for our webinar. We have Dr. David Weiss, is the director of the Orthopedic Trauma Division at the University of Virginia Health System. And he enjoys the challenge of providing complex fracture care to a wide spectrum of injured patients while working closely with the other trauma services at the hospital. After finishing his orthopedic trauma fellowship in 2005, Dr. Weiss spent the next five years as medical director for the orthopedic trauma at St. Joseph Mercy Hospital, a level two trauma center in Ann Arbor, Michigan. Dr. Weiss has a lifelong interest in teaching and education and is able to fulfill this by interacting daily with his residents and medical students. We also have Michelle Pomfrey. Michelle began her work with trauma registries in 1993 by establishing the University of Virginia Health System Registry Program. She joined the American Trauma Society in 1994 and was a founding member of the Trauma Registers Council serving as their first elected chair in 1996. Michelle served on the ATS Board of Directors for 16 years. She established Pomfrey Consulting in 2000 and has been serving the trauma community throughout the country ever since. And finally, we have Stacey Hairston. Stacey is currently the ICD-10-CM-PCS faculty and content expert at Pomfrey Consulting. She is also a full-time professor in the Health Information Technology Program at Southwestern Illinois College. She has been teaching courses in health information technologies for nine years. Stacey has a diverse background with over 10 years of healthcare experience working with several healthcare settings, including pediatrics, managed care, and physician offices. She also has six years of consulting experience focusing on healthcare data analytics. So welcome to our panel and we'll get started. All right, I'm going to get started here with the hip fracture portion or the clinical portion of the presentation. Do we see hip fractures in trauma coding? All right, Michelle's smiling, so I assume that means it's good. Okay. So I thought it would be helpful to look at some of the clinical things that we do with hip fractures. So I know many of the people on this webinar are involved with coding and are extracting data from charts and things like that. But I thought that we could talk a little bit about the clinical things that we as physicians do when we look at hip fractures. How do we make the diagnosis and what are some of the issues that you as coders maybe see in the chart, but now you get to see maybe more of a visual representation of what we're looking at clinically and talk about some of the decision-making that we do for hip fractures. So first thing to recognize is that hip fractures come in different flavors. And so what do I mean by this? It's, you know, there are a lot of, you can show an X-ray that has two very similar looking fractures and you can come up with two very different treatments for that. And that's because it's really important to understand the type of hip fracture, the location of the hip fracture. And remember that the hip is attached to a person and that person may have very different needs or very different functional levels or very different expectations about their function. And this drives some of the different decision-making that we have when we think about how to treat these. So as an example, I'm going to show you two X-rays here of femoral neck fractures. So to orient you, for those of you who are not familiar with looking at X-rays, this, and my cursor is sort of outlining the pelvis here, the pelvic, the iliac wing, and then this is the hip, the ball part. And then there's a socket part here. And we'll talk in a minute about how we define different areas of the hip, but I just want you to look at these two fractures. And here we see a fracture that's in the femoral neck of this hip on the left. And then this hip on the right-hand side of the screen, these are both right hips, is also a femoral neck fracture. And this fracture line is right through here. But the type of fracture that we see on the right is actually much more common in younger people with more high energy injuries, like riding a motorcycle or maybe a high level sports injury or crashing, skiing, racing, or something like that. Whereas the fracture on the right-hand side of the screen is much more associated with an elderly infirm person who maybe has a ground level fall. Those are both femoral neck fractures, but we look at them differently and we treat them differently because the patients are somewhat different. And so we'll go into that in a little bit more detail in a moment. These are the objectives for the talk that I want you to understand. So we're going to talk about hip fracture anatomy and how the blood supply is important. We're going to quantify what we mean when we talk about different types of hip fractures. How does that impact where they are and how we treat them? We're going to talk about the different treatment options in each location, and then how some of this decision-making occurs. And then we'll look at some of the implants and we'll look at fracture treatment options through these x-rays. So the first thing to think about is the anatomy, because when we're talking about the hip, we want to make sure that we're all on the same page. And we want to think about how the hip is constructed and then how these forces are applied to the hip, because these will really affect what happens after you have a fracture and what forces we have to sort of fight as orthopedic surgeons to keep the hip well-aligned during the healing phase. Because once an injury occurs, the body's going to want to try and return the hip to that injured position unless you can hold it in a better position with fixation. So this is a drawing of the hip, and it's a little bit hard to, if you're not used to looking at hips, but this is the ball part, the femoral head, and then this is the neck part. And this is what we call the calcar or the lesser trochanter and then this is the shaft of the femur. And this is a cross section here of these things. And what's important to realize is that the bone is very dense and thick along this medial and calcar region. And so it's important that when there's a fracture that goes into this region, that we really try and shore that area back up because the stresses that are applied there are very heavy and can affect that. The other thing to know is that there's a lot of density around the ball of the femur, and there's a fair amount of density around the calcar, but the area in between the ball of the femur and the calcar tends to be much less dense. And so on this picture, you can see a lot of these sort of thick black lines up here in the head, not quite so many in the neck, and then more of them down by the calcar, and that just represents, just like a contour map does, it just represents the density of bone in those areas. And then the muscles that attach are important, and it's not important for you to know all the different muscle functions, but it is important to realize that the abductor muscles, which are here on the outside part of the butt muscles or the lateral muscles in the thigh, serve to sort of shorten and externally rotate the leg. And the flexors of the hip, which are the iliopsoas muscle here and some of the quadriceps muscles, anytime there's a fracture that occurs, particularly around the hip, these muscles will shorten and tend to deform those. And so that's the first thing to realize. The second thing to realize is that our bones are slightly curved, and particularly the hip. If we look at this image over here where the muscles aren't present, you'll notice that the hip bone is actually somewhat curved and that your weight-bearing axis as you walk kind of goes right down through the center there. So this black line here represents that weight-bearing axis. And that means that the forces that are applied on the hip, this proximal area, are really a lot of bending forces. And so there's a lot of what we call varus force, meaning wanting to bend the hip in this angle. And so we have to be able to resist those varus forces. So that's why that medial calcar is so strong, because it's got to be able to resist those forces. And when that's broken, you have to really be able to somehow replace the function of that, at least until it heals. This is a sort of representation of the different types of fracture patterns that can occur. As fracture intensity goes up, as the mechanism of injury and the energy absorbed goes up, these fractures tend to get more vertical. So they start off somewhat horizontal, which is a relatively stable position if you can think about this arrow being the weight-bearing force. Compressing these two pieces together will actually lead to some stability and some increased likelihood of healing. As this fracture line moves more vertical, then the forces that are applied create more of a shearing-type force, and that creates more problems with stability. And so what we see here is these increasing shear forces moving from the left side of this image to the right. And so fractures that are involved with more vertical femoral necks are harder to treat. They're more likely to fail, and you have to kind of take that into consideration as you decide how you're gonna treat these. Here's an example of what we're talking about. This is the hip, and this is, you can imagine, a fracture that's outlined here on this red line here. This is the reduced position of this fracture. And for the purposes of this drawing, we're talking about the femoral neck right here, but this could also be considered this region out here that we're gonna talk about in a bit called the intertrochanteric or subtrochanteric region. The forces that are being applied are similar. And so here you see the hip in this reduced position, and here's the axis that's formed. It's about 130 to 135 degrees. That's kind of the normal hip axis. Now, if you have these varus forces putting on it, and you're not resisting that position for that load, then the hip is gonna collapse into varus, and you're now gonna see an angle that's closer to maybe 100 or 110 degrees, and that's less desirable for both healing, function, pain, et cetera. And so it's harder to get things to heal in this position, and it's certainly not as functional. One of the decisions that we, some of the reasons that we make decisions have to do with the likelihood of healing, and the likelihood of healing depends on the blood supply. So the blood supply to the hip, if you look at these diagrams here on the bottom, recognize that the blood flow comes up into the hip, and it goes inside close to the bone of the hip, and it's contained by what's called a capsule, and the capsule is a thick band of tissue that's represented here in this drawing by this ring here, but it also, it envelops the whole hip. This is the capsule that's been cut so that you can see the inside. You can think of this like the head gasket on your car. It kind of contains the fluid within the hip joint. You have capsules around each one of your joints, and the hip is particularly thick. And so we define what's called the intra and extracapsular region. So the intracapsular region is the region inside this capsule, and the blood flows through this along the femoral neck, and most of the blood supply is actually along the posterior aspect of the neck. And you can see it in this drawing here where they've put some dye into the blood vessels, had the blood vessels come up and kind of go into the neck here. And so if there's a fracture that disrupts these blood vessels, particularly inside the capsule, the likelihood of healing goes down. And so when we see that, and we see that the likelihood of healing is down, and the patient is older, it tends to lead us more towards replacement as opposed to fixation. When the patient's younger, they have a better healing potential. The blood vessels can reestablish themselves. And also joint replacements don't do as well in younger people. And so we tend to think about more repair as opposed to replacement. So let's look at specifically at some locations. So again, here's a drawing of a hip. Here's the ball. Here's the neck. Here's the shaft of the femur. And so we sort of break the hip up into four parts. We have the femoral head. So you can have fractures that involve the head itself, sometimes associated with a dislocation, sometimes not. We have what's called the neck. So this next region is between the ball and the trochanter, trochanters. And this is the femoral neck. And you can have a fracture that's right at, just below the ball, what we call a subcapital, or you can have a fracture that's in the middle of the neck called the transcervical, or at the base of the neck called the basocervical. And these are all considered intracapsular fractures. And then we get down to this next region between the greater trochanter and the lesser trochanter, and this is called the inner trochanteric region, or IT. And then we have this region down here below the lesser trochanter called the subtrochanteric region, or ST, subtrochanteric. And so as you move along this continuum, the forces, again, are those varus forces, but because of the varus structure, because of the structure of the bone, the ability to resist varus depends on the location. And that's, again, how our implants are often chosen. Down in this trochanteric region, we have sort of three different types of fractures that we think about. One is the type one fractures, and these are simple fractures. And so you can imagine as this force comes down through the neck of the femur, that these fracture will be nicely compressed, and the shearing will be minimal. And there's a lot of surface area here. And so these fractures can be very stable fractures once you get the right implant in them. Moving on, this fracture line can extend and split and involve that medial calcar. So now the fracture line is running more inferior. These are not quite as stable because once you lose that calcar, you lose some of that medial support. And so fractures in this region are harder to stabilize and need a little bit more thought. And then we have what's called the subtrochanteric region, and this is down here around the lesser trochanter or just below it. In this region, again, the fracture forces are even higher, and you have to think about how to neutralize that various force. And so when we're dealing with a fracture, we have to decide, well, what implant should we use? And so if we're gonna fix a fracture, we have to say, well, how do we fix it? And what do we have available? And so our basic implant choices, and there's some variations on the theme, but just breaking it down into basic categories, we have screws, we have plate and screws, we have intermediary nails, and we have both short and long nails, and then some also sub-variants of intermediate length nails. And then we have replacement, and we can do a partial replacement or we replace the head only. We can do a total replacement where we replace the head and the cup or a THA, total hip arthroplasty. And then do we use cement to help put the cup in or put the stem in, or do we use press fit techniques, maybe augmented with screws? So how do we decide? That's one of the challenges of taking care of hip fractures is how do you decide which implant to use? So we'll go through some options here. So starting with screws, this is a diagram or a drawing of a picture of a cadaver model. And you can see, again, that dense bone up in the femoral head, not quite so dense in the neck and a little bit denser down here in the cortex of the shaft, this thickened bone, the calcar femorale, the femoral medial calcars, that nice thick bone. And ideally, if we're gonna use screws to fix a fracture, like is shown in this picture here, the screws will cross over the fracture site. These are lag screws, so they will compress through the fracture and will park that lag screw right next to that calcar, such that when the hip is loaded, the screws are able to resist that load through this buttressing effect. On a side cut view or on a view that shows the detail here, you wanna see these screws parked right up against these cortical line and not too far in the center or the bone will shift until it hits the screw. So if the screw is not placed in the right position and you load this hip, then this hip's gonna shift until the screw does have a chance to hit into this cortex here. And so that's why screws are not the best treatment for many of these fractures because the positioning is very critical and just based on their mechanical nature, they're just not that strong in resisting these forces. So we do use them for certain fracture patterns, but they're not as, they don't have as much strength as you'd like to see. A more common implant used for fixing femoral neck fractures would be a screw and side plate. Here, instead of an independent screw, you've got one big lag screw that goes up and connects to a plate that has a variable number of screws in the shaft, usually between two and four. And this plate will slide, so this screw is in a barrel and that will allow it to compress across a fracture as we're gonna see in a minute. So this is what we call controlled collapse and this encourages the fracture to compress. And bones like being compressed for healing and so a fracture that is being encouraged to compress and allowed to do so will subsequently likely heal faster. And so here we have an intertrochanteric fracture on the left-hand side of the screen where we have a fracture line that runs from the greater trochanter to the lesser trochanter. It's a little hard to tell what's going on because of the overlap of the proximal segment and the distal segment, but that's essentially what's going on. And when this is reduced, I've drawn the fracture line in here in red, but you can imagine that this screw here that's through here, if this is allowed to slowly back out through this barrel, then there'll be a lot of compression applied across this red line and that will help with the healing. And so this is a lag screw and it's a screw and side plate device. You can also use intramedullary implants, intramedullary nails. We have both short nails and long nails to fix these. And there are some advantages to intramedullary nailing. By using a nail, you can make an incision up here away from the fracture site and insert the nail and so that you stay out of the zone of injury somewhat. You still have to make an incision over here to insert this lag screw. And nails from a biomechanical aspect by putting the nail a little bit closer to the fracture, the lever arm is less. So remember these bending forces that we talked about. This yellow is a screw and side plate and the side plate's gonna get pulled on a little further away. And so the moment arm is bigger than the nail. And also if this fracture does compress and this femoral head starts sliding this way, it's gonna hit the nail before it hits the side plate. And so that in theory, you'll have controlled collapse to a point and then the nail will stop that and help backstop it and keep it from collapsing more than you may say want it to. And so for unstable fractures that are likely to shift and move around some, it's a better implant than the screw and side plate or the plate device. And there are some mechanical advantages here as shown. If we're gonna talk about a replacement, we have to think about whether you would do a hemiarthroplasty. So this is an example here of a partial hip replacement where just the ball is replaced. The cup is still the native cup. And then are you gonna use cement or no cement? And so cement allows you to put a layer of bone cement around the prosthesis and down into the shaft a little bit as shown here that helps anchor the bone, but may long-term lead to some loosening if the cement technique is not very good. And so when they first started putting in hip replacements with cement, they were lasting a good 15 years or so, but then they developed some techniques where the implant itself could have some beads or some changes in the metal, roughening the surface and allow the bone to grow into that surface. And that would in theory lead to a lifelong implant. And so cement has gotten less popular as people get older, but it's still very popular in the elderly hip crowd because oftentimes their femurs are more hollowed out and it's harder to get an implant that fits directly against the cortex because the inside of the cortex is relatively thin and the bone is somewhat hollowed out as people age. So cement is a useful technique in hemiarthroplasty for fracture in older people. So I thought we'd just take a quick walk and show you some examples of some fractures moving from the femoral head down to the subtracontaric region. And these are just some clinical examples of patients that mostly I've taken care of and all my partners have taken care of and just show you some examples of what we're talking about. So a femoral head fracture, these can be a little hard to see on X-ray. And so I've shown a CT scan here. If you look at the left side of the screen, which is the patient's right hip, you'll see a fairly round ball that represents their uninjured side. If you look at the other side of the screen, you'll see this ball has been sheared, the hip dislocated and sheared a section of it off. So the ball is like a kind of flat side. And we fixed this by relocating the hip, flipping this piece around 180 degrees and putting it back to that ball with these two small screws that are cannulated and have variable pitch on them to allow them to compress. And so by putting the hip back in place, flipping this piece around and putting these screws through the hip in a way that keeps the screws out of the zone of injury, keeps them out of the way, we can countersink them slightly so they don't catch on the hip and they're very low. So the likelihood of them engaging the acetabulum is low as well. And that can lead to some predictable healing at the femoral head. Here we see our femoral neck fracture. This is a fracture in an elderly person. It's a subcapital fracture. So there's very little room to get fixation up in here because the amount of space that's left is just small. This patient's older, very osteopenic, their bones are quite thin, their cortices are quite wide. And they'll go on to get, so here's the fracture, and they'll go on to get some sort of arthroplasty, in this case, a hemiarthroplasty, which is a good treatment for patients who are older, maybe frail, maybe demented, and just need to have the hip replaced so they can start getting up and around. Over time, this ball will start to wear on that acetabulum, and generally say five to 10 years is usually the limit for these, although people have certainly had them much longer and done well with them. But that is certainly one of the issues with hemiarthroplasty long-term is that their function is not as good as total hyparthroplasty. And so here's an example of a total hyparthroplasty. Here's a patient who'd fallen, and again, maybe a little subtle in the fracture if you're not used to looking at these. If you look at the right side of the screen, the patient's left hip, this is what a hip is supposed to look like. On the opposite side, the hip has collapsed a little bit. It's shorter distance between the trochanter and the ball, and that's because the ball has fallen backwards and actually fallen into valgus, which is a stable position, but still oftentimes results in a lot of pain and instability from people trying to move around. And so these are often indicated for surgery. And in this case, the patient had a little bit of preexisting arthritis, a little bit of narrowing up in here. And so we use templating. This is our software that templates off the opposite hip, and that can tell you sort of what the hip used to look like, hopefully. And then you can put in an implant. In this case, got a PressFit implant with a total hip cup and ball. And if you have a young person who has got a femoral neck fracture, so here we have this patient who's got a fracture that involves the femoral neck, and it's close to the intertrochanteric region, but it's still the neck. And sometimes it's hard to tell exactly how bad the fracture is. So we get a CT scan that usually shows exactly how bad the fracture is. And here we see that it's not right below the subcapital area, but it's really still in that neck area. And these are somewhat emergencies. They usually have to be fixed fairly expeditiously to prevent the blood supply, again, from being knocked off. And in this case, we chose to fix this with first a small plate and then a wire to help line it up. And then we changed this out for a longer plate, screw inside plate, and some additional wires to help give it extra stability. And again, stabilizing that fracture and allowing that to compress and to weight bear. And then we added some extra screws outside the plate, again, because it's such a comminuted fracture so that we can put the screws against the anterior and posterior cortices and help with the overall reduction stability. Here we have a fracture that looks like a relatively simple fracture pattern. We have a fracture line that runs from the greater trochanter to the lesser trochanter. Tiny bit of comminution, but it looks like this would be one that would be well amenable to sort of compressing it together with a screw inside plate and letting the patient walk on it. And that would be a pretty easy surgery. However, surprise, one of the reasons we have to get full length films on these types of patients is that there can be surprises hiding below. And this patient had a previous femur fracture that had been treated with a plate and screw. And so if we use a plate and screw fixation and we take a lag screw and put it in right here and run the plate down to right here, then we have two plates that are fairly close to each other with a space in between. And that's a recipe for disaster. If this patient were to fall again, these stress risers of the plates would concentrate all the force right in between them. And so they would get a fracture at that gap. If you say, well, I'll just put a rod or a nail down this patient. Well, the nail's only going to go so far before it hits the screw. Or should I use a different kind of a plate that maybe is very short or maybe very long and somewhat overlaps this plate? People choose different answers for this, but in essence, one of the options is to use a nail, but also take out some of the screws in the plate and sort of work around it. So that's what we did. We put a nail in, helped stabilize that proximal fracture. We took out some of the screws in the plate, put the nail down so it overlapped the plate and then put new screws back in. And sometimes we'll have to work from the other side of the body to do that because the plate's in the way, but this time we were able to work around the plate or through the plate. And so that leads to stability of this fracture here. but maintaining the stability down below of their previous fracture. Then lastly, subtrochanteric fractures. We'll see on this one, this injury doesn't look too bad. This patient's got some arthritis, a little bit of bone spurs and narrowing up here, and there's a fracture line that's hard to see on the AP view. I've drawn an arrow to it. You can see it extends down below the lesser trochanter and the subtrochanteric region. Here's where a lateral view is very helpful. I'm not showing laterals in most of these because I'm just trying to highlight certain things, but we always want to have at least two views of every fracture. And here you'll see there's a lot of comminution. There's a lot of splitting of the bone and the pieces are actually fairly far apart from each other. And so we need to line those up and get them stabilized. And so again, that's going to get some sort of a long nail fixation most likely. And in this case, just a standard long nail with interlocks distally to help prevent the nail from shortening or spinning. So in summary, we talked about how the anatomy of the hip and how that blood supply affects the choice of surgery and what we might choose to do with surgery. If we have a fracture that involves the blood supply that's likely to have killed off the hip, then replacing it is certainly a good option. If we have a fracture where replacing the hip is not a good option because the patient's very young or we can restore the blood supply and those extra capsular fractures, then we generally try and fix those. We looked at the location of hip fractures, the femoral head all the way down to the subtrochanteric region. We looked at those various forces that are applied and how you have to resist those. We talked about a lot of the implants that are available and sort of the classes of implants. And then we went through some extra examples of using those implants based on the fracture pattern. So I'm gonna stop sharing my screen now and I'm gonna see if there's any questions. If you have any questions, you can put them in the chat and I will relay them. I do have one question, Dr. Weiss. Here in Ohio, we struggle a lot with periprosthetic fractures in the elderly. Do you consider those to be more of a stress-related or a complication from a previous fracture? Say the first part again, do I consider them to be a, what was the first question? Part of a stress, type of a stress fracture. You have the elderly that have the brittle bones and maybe it's related to a stress, stress more than a mechanism of injury. And can you just touch on that a little bit? Yeah, so generally, like I talked about when I was showing that example of the fracture of above where they had a previous fracture below. One of the problems with having implants and whether it's a hip implant or a knee implant is that the implant creates a lot of stiffness in the bone. And so the bone is somewhat protected around the implant but right where the implant ends and your native bone begins, then there's what's called a stress riser. And so when people fall, the implant tolerates the stress usually pretty well but the stress is transmitted right at the end of the implant and then it tends to break right there. And so that periprosthetic region then is typically, it's a true fracture, but it happens in that area because the stress is transmitted to that area because of the implant. So periprosthetic fractures are common. I didn't specifically talk about those because they usually are involving the femur shaft but not necessarily the hip so much. And so, but it is typically, it's a hip fracture, it's sorry, it's a femur fracture. And it's certainly related to the fact that they had a previous implant, but that has more to do with the location of the fracture and how you have to fix the fracture as opposed to not really being a stress fracture. It's not often something that builds up over time and then suddenly fails. More often than not, it's a fall or something that happens that just transmits the stress to that area. Does that make sense? It does make sense. And we have a lot of questions about this. A lot of people struggle with these. They want to know if these should be included into the registry because they struggle whether they should go in or not go in or if they fit into that category of pathological fractures. Generally, they're not considered a pathologic fracture, periprosthetic fracture is usually not a pathologic fracture. You can argue whether osteoporosis is something, makes something a pathologic fracture and it gets a little bit down in the weeds because some people don't necessarily have a diagnosis of osteoporosis, even though they might have it. A true, we think about a true pathologic fracture as someone who's got cancer and metastasis and so weakness in the bone. Osteoporosis is a disease that causes weakness in the bone. And so certainly a pathologic fracture, sometimes it's considered pathology and disease but it gets a little bit hairy because again, probably half the people that we see at our institution who have had a hip fracture have not necessarily been diagnosed with osteoporosis even though they might have it. Okay, thank you. And then I have another question here that came in and wanted to know, is a return to the OR common when an IM nailing of the femur is performed in young adults? Return to the OR for what, did it say? No, it just says, is it common? Is it a common event? It should not be. Occasionally people have irritation of their hardware later on and so we go back to the operating room to take it out. But usually intramedullary nailing in femurs is well tolerated. And so if you have a fracture that is not reduced well and needs to be changed, that sometimes happens. There's a small non-union rate in femurs and so it's about 5%. And so someone who's got a non-union of their femur would get a return to the OR. But typically, no, we don't think about femurs in young adults being typically returned to the OR for that particular problem. If they're a polytraumatized patient, they might be going to the OR for other reasons, but poor reduction if somebody chatted in, chimed in with poor reduction. If there's poor reduction, then yes, that is a reason to return them to the OR. Okay, thank you. And our last question for you, and then we'll move on, is I had somebody ask, is a gamma nail considered an intramedullary nailing? A gamma nail is a trade name from a company called Striker. And that is a, so yes, it is a type of intramedullary nail, but it's a trade name. So each company has their own fancy name for their nails and for Striker, they call their nails gamma nails. Okay, thank you. Next up is Stacey. All right, thank you, Maria. I'm gonna share my screen to open up. And I see a lot of questions have come in around the coding when it comes to really the information that Dr. Weiss has described. And I think your overview of when it comes to, just trying to change my screen here. Okay, there we go. When it comes to hip fractures, I think you did a really good job to make my lecture kind of easy to go through when it comes to how do we code these type of hip fractures. The first part I wanna focus on is going to be the diagnosis part. When Dr. Weiss goes through and he went through the anatomy to describe the type of fracture that a patient would have. It's first thing, let's just talk about, when we talk about trauma codes, these are gonna be your S codes that you're gonna assign. There were a lot of questions that came through after his overview of hip fractures, I think Maria, you mentioned the periprosthetic fractures. Those would actually be coded with an M code. So by definition, trauma codes are gonna be S codes. So any of those codes with the range that start with S, whereas those M codes are gonna fall under the pathological fractures. Note that M codes, and I put this here, should be used with any patient that has a known, and the key word there is known osteoporosis. Now that has to be documented within the record by the physician who suffers a fracture. Even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal or healthy bone, and it would be associated with that condition, then it would fall under pathological codes, which would be those M codes. So in looking at the S codes, which would be those trauma codes that we would assign, Dr. Weiss did a very good job in really just what will be documented of describing the type of fracture. In going through the code book, and I like a lot of times, even though I know the electronic version is used a lot, kind of my core is always looking at how is it defined in the code book, because that then allows you to include the correct terms when you are entering it into the electronic version, is that we are each time going through, hip is gonna direct you to the femoral neck, either the upper end or the lower end, for you then to be more specific on what type of fracture it is based upon that documentation. Our range with all hip fractures are gonna be between S72.100 all the way down to S72.099, making sure you're picking up that seventh character. So this would be the range of diagnosis codes that you should be assigning when you are inputting a hip fracture. Now, in looking more specifically at that seventh character, this would be the key to make sure you are identifying the correct seventh character. And it will be more specific, not just assuming it's always A as the initial encounter for this, the episode is, if it is a closed fracture, then it would be A. But if it's documented as an open fracture, we do have several options. For that acute setting, it's just gonna be these three. The others that are located within that seventh character table is gonna be more for those subsequent follow-up visits for that patient. So you have the B, which is gonna tell you it's a type one or two, which is based on the gastillo classification, kind of going into more detail around that type of fracture. And then C will be a little bit more severe of type 3A or 3B or 3C. If that information is not available, based upon coding guidelines, you can use the actual B if it is documented as an open fracture, not otherwise specified. If you're not familiar with kind of what that abbreviation means, it's stating that it is not and was not available in the documentation as far as more detail around that open fracture. So by default, then you could use the character of B. Some other key things, just guide coding guideline rules when it comes to the documentation of either if it's not documented as displaced or non-displaced. The default is always to go with displaced. If it doesn't state if it's open or closed, again, this would be another default that then you would go with documenting as closed. The key is to have as much documentation as possible, but as those coding guidelines, these are some of the coding guidelines that are given to us in order to proceed with the coding. I had a question earlier come in around complications and T codes. If there is a complication that does occur, then you would just go under what that complication is and document that type of complication. A question around if it was an intraoperative kind of complication that happened, there are a couple of ways of how you could go about in locating those. One of those is you could go under traumatic and that the femur, and then there's an option of following an intraoperative kind of insertion. Notice those codes are gonna be M codes. So it's very careful of what you're inputting in your registry that it does fall under those trauma codes. Because remember, this is why I started with the first slide that those M codes are gonna be associated more with those pathological conditions. Okay, and I did see in some of the comments that many of your facilities are not inputting those M codes due to the fact that they are those pathological codes. The next would be coding procedures. All right, and based upon the description of the type of options that could be available for patients when it comes to hip fractures, the first is going to be if you are trying to do a reposition. Okay, so I throw a fixation, excuse me, would be the option. So this would be using the root operation of reposition. And I put the definition here of moving to normal or other suitable location. When you are documenting the procedures, it's very important to ask yourself what is the overall intent of the procedure? Just using the root operation of insertion because the device is going to be used would not be accurate in the fact that that was not the overall intent of the procedure. The overall intent was that fixation, that reposition of that fracture. So what I've done is put a snapshot and depending on the type of procedure that was performed based upon where, we have the actual saying when we think about the first three characters, okay, if we look at the code. And then from there, we would then document which of the body parts. And from there, we identify the approach. So just walking through the actual characters that would be within the code, you have several option of approaches. If it's open, percutaneous, percutaneous, endoscopic or external. For majority of the procedures that are going to be open, okay, percutaneous would be if some type of instrumentation is used such as a catheter to perform these procedures. And then endoscopic would be if there is some type of a scope that would be used for the procedure. So majority of these will be open procedures and the device based upon the description that Dr. Weiss gave of the nails, the screws, the different plates would fall under those internal fixation devices or an external fixation device. You have, and he also mentioned the intramedullary when it comes to particular type of nails. So depending on where that procedure was performed as far as specifically of the body part would then give you your options of what devices that could be used for that procedure. There's always questions of, well, what are some examples of the other devices such as the ring or hybrid? I always would like to point out that within the manuals for both for ICD-10-PCS, there is a device table. And a lot of those devices do have the actual trade name of the device and actually would be able to help you in identifying which of those categories they fall in because it is a small amount specifically of those devices for those other categories. The internal fixation device and external fixation device is majority of the devices that you will assign. And notice there's no qualifier when it comes to performing one of those internal fixation procedures. If we look at the other procedure which would be replacement. So if a patient has the hip replacement that's done, that's putting in a device that's gonna replace the body part. Again, here are options based upon where we are as far as where that body part, either the joint or the femur. If it's the joint, only option there is open. And then this is where we could have options of a synthetic substitute or we can have an autogamous tissue substitutes which is something that may come from the patient. Non-autogamous would be if it's not from the patient, just as an example of that, of when you would use that. And Dr. Weiss talked about if it's cemented or uncemented. I think a question also came in of what do you do if it's not documented for each of those, then that's where you would assign the Z. Or try to give further clarification if you can from the physician on what was used. Okay. Questions around, because these are the only two based upon the options and procedures that would be done would be the only two root operations that you would assign for hip fractures. As I mentioned, be careful not to just assign insertion because insertion is that you're just putting in a device, nothing else is being done. Where with reposition, you are inserting a device but that was not the ultimate decision, okay, that you would be doing. Okay, any questions? I was trying to get a couple of them on here. For a HEMI, do you code the hip joint surface? So you'll be still going through the same process of coding it, even though it may say HEMI, I don't know, Dr. Weiss, you cut your screen on, did you wanna? I don't know, Dr. Weiss, you cut your screen on. I don't know, Dr. Weiss, you cut your screen on. Dr. Weiss, you cut your screen on, did you wanna add something to that? I can't add to the coding part of it. Okay. You guys work your magic on the backend. I can talk about different, how you might define different types. I think I saw a question about cemented versus uncemented and it should specify either in the, it may not specify in the diagnosis or procedure but it should specify in the operative note because that's a definite part of the procedure. If they don't mention it all about cementing or using cement technique or using cement, then it's most likely uncemented. But I'm not sure exactly how the coding works. There are different types of hemiorthoplasties. There's unipolar and bipolar. And I'm not sure if the coding is different for those. They have the same function. It would be different. The code would be the same. Yeah. And certainly total hyparthroplasty is different because you're going on both sides as opposed to one side. I think there was a lot of questions I saw about the question you asked earlier, or you mentioned earlier about pathologic fractures versus periprosthetic fractures. And do you code this as an acute injury? I think that's a difficult question, right? So we, Michelle, you can probably best answer this. What we do at UVA as far as the, how these fractures are coded in the registry. But I believe most of them are included in the registry as acute injuries. And this is a clear definition. We call them, well, let's talk about hip fractures alone first. So even if it's a fracture that comes in a low energy, sometimes people have other injuries that are associated with them. So they might have a head injury. You don't know sometimes if someone falls down one step at that lower energy or high energy. We certainly see hip fractures occasionally in young people who fall from low heights, but usually they have some sort of problem with their bone that may be undiagnosed at the time. It can be hard sort of determine, and it's probably based more on your guidelines that you're either your institution or in your state, whether those kind of qualify. As we talked about osteoporosis oftentimes, or at least part of the time is not diagnosed in these people, even if they end up having it. And we might diagnose it later, sometime in the perioperative period. But when they're actually in the hospital and you're doing their coding, you may not know if they have a true diagnosis of osteoporosis. So that can, I think, affect sometimes how this goes into place. The term periprosthetic fracture, we use this as clinicians, because it's important to recognize we make some choices. Like I showed you in that, in one of those examples, when you have a fracture at the hip, but you also have, in this case, this gentleman had a plate down below. You have to change how you do your fixation based on that. And so that usually increases the time of surgery. It sort of may increase the, or may change how you do the rehabilitation. So you have to account for that. It can still be a traumatic injury and the hip or knee implant may not have necessarily played a role in the injury, but it can affect how you take care of the injury. And so we will typically note that in the operative note because it can affect our decision-making. How it affects the coding may be different, whether you're classifying that as an acute injury or whether it's more of a pathologic type injury. And that can be a tough one to parse out sometimes. We certainly don't usually give you the kind of information in the operative report that might help with that. For that, I apologize, but it's unlikely to change. Thank you. I want to leave some time here for Michelle because we are coming up on our one hour mark, but we'll let Michelle present her part of this presentation and then we'll have some more questions at the end. I'm writing them down. So I'm hoping to get them all answered for you. All right, thank you. So as we anticipated, lots of questions around hip fractures. So in this last portion of the webinar, I wanna talk about the National Trauma Data Standards, what the inclusion criteria states. We're going to look at the impact of these isolated hip fractures overall in our trauma world, where it relates to volume and potential medical costs. And then we're going to look at just very briefly how tracking these isolated hip fractures impact your institution. So this is the inclusion criteria algorithm straight out of the National Trauma Data Dictionary. And where I want you to focus a little bit is here in this second box. And Stacy's already alluded to this. This is your S codes. And so if the patient has a purely pathological fracture, typically not seen in high volumes in the hip, but they would be coded as a, I think Stacy had it as an M code. So we are looking at the pure fracture of, as Dr. Weiss described, the head of the femur, the neck, the trochanter areas. So those are going to be coded as S. So they clearly fall into the inclusion criteria for the college. Now, with that said, there are institutions that do not include isolated hip fractures as part of their trauma registry. That is disclosed to the college so that your facility will not receive benchmarking reports in the isolated hip fracture categories. So you'll be left out of those. There's also, I believe, a specific question in your pre-visit questionnaire about isolated hip fractures. So it is clearly part of the inclusion criteria. Now, over the years, institutions have moved more in line with capturing these types of patients. Now, I want to spend just a few seconds on some of the national statistics as it relates to these isolated hip fractures. So the most common mechanism of injury is a ground-level fall, and we do see that more in our geriatric population. We see more than 340,000 hospital admissions yearly in the United States related to these isolated hip fractures. Now, with that, that's nearly $3 billion a year in medical-associated costs. Over the next 25 years, hip fractures are anticipated to account for more than 500,000 admissions per year in our hospitals. When you start to look at the mortality of hip fractures, we see that in the first 30 days after post-op, after their hip has been fixed, we see a 5% to 10% mortality rate, and that increases to 12% to 37% within the first year after surgery. So what we're looking at here with our fractures, our isolated hips, we're talking about an elderly population, our geriatrics, and so where do we have good statistics? And so that's why the college has isolated hips as part of our inclusion criteria. So we're getting that full picture of how isolated hip fractures, the geriatric population, their morbidity, their mortality, their cost, all of those things are being able to be researched and evaluated when we look at the national data set. So when you start to think about these isolated hip fractures, what we want to think about are the challenges. So 52% of isolated hip fractures occur in the patient population age 80 or greater. So now I want you to think about that patient population. So they have predominantly more pre-existing conditions than a younger population. So when you start to look at your TQIP data, you're going to have your risk adjusted outcomes because of the pre-existing conditions. So that's another caveat. You need to make sure you evaluate these charts completely to capture all of the pre-existing conditions. They have a higher mortality rate a lot of times because of their pre-existing hospital or pre-existing conditions. Now, one of the unique things about this type of trauma patient is they're typically admitted to an internal medicine service, not always, but in most cases. That internal medicine service is going to monitor and treat and keep their pre-existing conditions in check during their hospitalization. And then orthopedics is going to treat the fracture. So in treating that fracture in doing this joint care, they're admitted to internal medicine. So what happens there is your non-surgical service rates for your institutions go up. And I'm going to talk about that here in just a moment. So now that we have a geriatric population, 52% over 80, lots of pre-existing conditions, a higher mortality rate, then we also have a higher risk of hospital events. So them developing complications, stroke, a heart attack, a DVT, a PE, and so forth. So they are an at-risk population. So now let's get back to being admitted to your non-surgical service. So even though they're co-managed by Ortho and Ortho takes care of all of their fracture-related treatment and so forth at their care, they're still admitted to a service as a trauma patient that cannot do surgery. And so the college looks at that as being an indicator for your hospital of the patients that you care for. What is your non-surgical service rate? And if your rate is greater than 10%, the college expects you to have some type of performance improvement review of those patients. And so this higher rate for your hospital can get you into that 10% mark. So if you're in that 10% mark, here in the table one that you see on your screen are the indicators for using the Nelson score. And the Nelson score is a fantastic article that's out there, but this is the easiest portion of the article, very easy to look at. You would simply run a report in your registry looking at these fields. So you're looking at the age of the patient, how many comorbidities or pre-existing conditions did they have? What was their ISS, their mechanism of injury? ICU days, did they go to the OR and did they receive blood products? So for each one of these categories, you give them a point, you add up the points. And so if this patient has six to seven points, then that is a very appropriate non-surgical service admission. If they scored four to five points, you probably need to dig into that case just a little bit more from a performance improvement standpoint. If the patient had less than four points, research has shown that it is an inappropriate non-surgical service admission. So if you're thinking about that, you're looking at somebody that either had a higher ISS, had an ICU admission, maybe went to the OR, maybe had blood products. So that is those types of conditions are usually seen in patients that need to be admitted to a trauma service. So as you dive into these isolated hip fractures, where you start to track your Nelson scores, what is your non-surgical admission? You wanna track this on your dashboard. And in your dashboard, you can track on a monthly basis what your non-surgical service admission rates are and where of those patients they fall. Range six to seven, four to five, or less than four points. So you can see whether your admissions to the non-surgical service are classified as inappropriate, needing further review or an appropriate review. So let me see if Maria, do we have any questions? Yes, we have a lot of questions. If I could just ask the panelists to stay on a few extra minutes here. Lots of coding questions. So I'm gonna set these to Stacy. There was a question about if a patient has a hip replacement and they have a reoccurring fall on that same side below the implant that they had placed on the first fall, would you code that as an S code or would you code it as a M code? You're on mute. Okay, I'm sorry. You repeat the question so I can kind of get each detail. I think what they're getting at is the whole periprosthetic stuff. So their question was, they had a patient that had a hip replacement. So they had an implant in place. A previous replacement. They fell, yes. And then they fell again on that same side. Would you code that fracture as an S code or would you code it as an M code? It says it's below the first implant. So the fracture's below the first implant. It would be an S code. Okay. And when would you use a reposition code versus a repair or replacement code? Okay, so reposition. Reposition versus repair. Yes. Is that your question? Okay, reposition versus repair. So repair would not have anything to do with the device. Okay, so if it has anything to do with that reposition and that device is involved, then that's when you would use that reposition. Repair is not gonna be used when you are, if it's dealing, you know, repair is like suture and a laceration or something like that. It wouldn't have anything to do with if you are trying to repair a fracture, then it's going to be the root operation of reposition. Okay. And then finally, I think this is going along with the coding rules of, you know, the washouts are inclusive in some of the other procedures that we do, because I'm trying to understand this question, but it says, are distal femur replacements at the knee joint and a proximal tibia replacement considered all inclusive when coding the procedure? Or would they be two different codes? It's gonna be dependent on the table and how it's identified within that table for that body part. That's when you would determine if it'll be two codes or one code is based upon, how does the table specify that body part? Does it specify it as one code or two codes? Okay. And then I have a couple of questions for Dr. Weiss. I had a question about blood loss with surgeries. And I know that you hit on some of the blood vessels in your lecture and stuff. The question was, patients receive blood, a lot of patients receive blood 24 hours post-op versus intraoperatively. Yeah, it's common for patients with hip fractures to lose some blood both at the time of the injury and from the surgery. Many of these patients are elderly and may come in with a low blood count to start. You might have a hematocrit in the low 30s or high 20s. And if they have any cardiac history, we tend to be a little bit more aggressive about transfusing them typically when they get to eight, hemoglobin or hematocrit of around 24. And if they're non-cardiac, then typically we'll let them drift down to around seven of a hemoglobin or a 21 hematocrit. But it is fairly common that these folks will get blood transfusions. I'm not sure how that changes the coding part of it. Okay, thank you. And then I have a question for Michelle. Somebody had asked if a patient is admitted for a fracture because they needed OR, but later ortho decides that they do not need surgery, would you change the admit service to non-surgical? No, we would keep track of the admitting service. So I think all of the PRQ questions that you have to fill out before an ACS site survey, state admitting service. So you may track it internally for your own tracking, but for your non-surgical service admissions, it would be the admitting service, not who they're transferred to later on. And then last but not least, I have a question about how do you know which kind of synthetic substitute was used in the OR? That can be a tough one, because as Stacey was going through, there's a lot of different variations on metal on poly, metal on ceramic. You're talking about for hip replacements, I assume in this one. Typically it's said in the operative note, what materials were used. So you would see, now we used a metal head size 32 with a plus five offset, and the cup was ceramic this, or polyethylene this, or whatever. So it will typically be said in the op note, what devices were used or what materials were used. I don't know specifically, you might see something like we used an attune hip, which is a, say a J&J product, or maybe you might use the trade name for the hip. I think somebody mentioned is it's something they can Google. And one of the problems is sometimes you have different options. So you might have an attune hip and you could have a metal head, you could have a ceramic head, you could have a poly cup, you'd have a ceramic cup. So you probably have to closely read the op note to see if you really didn't know. At our institution, we use an EMR, we use Epic EMR, and in Epic, it logs the implants that are used. So if I forget what length screw I used for a particular thing, and that was really important, then I know that I can always look in the operative record for that patient and see, because every screw is logged or every implant is logged by the nurse. So if I really needed to know something and I didn't know who to ask, you could always look in a record and electronic medical records should capture that at least in many instances. So hopefully that's helpful. And if it does have that name, as I mentioned earlier, that PCS device key does have the different trade names and other information for you to be able to align it to which character you should use within the table. Okay, well, thank you, everyone. This concludes today's webinar on hip fractures. I want to thank our panelists, Michelle and Dr. Weiss and Stacey. And this concludes everything. Have a good weekend, everybody. Bye-bye. Bye-bye, thanks.

hip fractures

anatomy

treatment options

coding

screws

plates

total hip arthroplasty

fracture severity

procedure documentation

patient care