Hip Fracture ORIF (Intertrochanteric / Femoral Neck)

CPT 27245 · 17.73 wRVU · 90-day global
CPT27245
wRVU17.73
Global90-day
ApproachOpen
ComplexityComplex
Preoperative Diagnosis:

Right [left] [intertrochanteric / subtrochanteric / femoral neck] hip fracture, [displaced / non-displaced] [/ AO/OTA stable two-part / unstable with comminution / reverse obliquity / with subtrochanteric extension]

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] hip fracture closed reduction and internal fixation, [cephalomedullary nail (27245) / dynamic hip screw (27244) / cannulated screws (27235)]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

Spinal [/ general endotracheal]

Indications:

The patient is a [age]-year-old [male/female] who sustained a right [left] [intertrochanteric / femoral neck] fracture after [mechanism: fall / low-energy trauma]. The fracture is [displaced / non-displaced] [/ AO/OTA stable two-part / unstable with comminution / reverse obliquity / with subtrochanteric extension]. Operative fixation was indicated. The risks, benefits, and alternatives were discussed with the patient [/ family].

Findings:

Under fluoroscopy, the fracture was reduced to [anatomic / near-anatomic / acceptable] alignment in AP and lateral views. The [cephalomedullary nail / DHS] was positioned with the lag screw in the center-center position of the femoral head [/ center-inferior in AP, center-center in lateral view]. Tip-apex distance was [<25 mm]. Final fluoroscopic images confirmed acceptable alignment, restoration of neck-shaft angle, and no articular penetration.

Description of Procedure:

The patient was positioned supine on the fracture table with the operative extremity in traction and the contralateral leg in a [scissor / hemilithotomy] position. Closed reduction was achieved under fluoroscopy by [traction / internal rotation / positioning]. Reduction was confirmed in AP and lateral projections.

[CEPHALOMEDULLARY NAIL:]
A [3–4]-cm incision was made proximal to the greater trochanter. The abductors were split longitudinally. The entry portal was established at [the tip / just medial to the tip] of the greater trochanter with an awl per the implant system's specified entry point. A ball-tipped guidewire was advanced into the femoral canal. Sequential reaming was performed to [X] mm (1.0–1.5 mm above nail diameter). A [X]-mm diameter × [X]-mm length cephalomedullary nail was inserted to the appropriate depth. Under fluoroscopic guidance, a [125° / 130° / 135°] angled guide was used and the lag screw guidewire was advanced to the center-center position [/ center-inferior in AP, center-center in lateral] in the femoral head, with tip-apex distance confirmed <25 mm. The lag screw was inserted. A distal interlocking screw was placed [freehand under fluoroscopy / with jig]. The set screw was tightened. Final fluoroscopic views in AP and lateral confirmed acceptable alignment, implant position, and no articular penetration.

Wounds were closed in layers. A sterile dressing was applied.

Complications:

None

Specimens:

None

Estimated Blood Loss:

[X] mL

Drains:

None

Disposition:

The patient was taken to the PACU in stable condition. Weight-bearing as tolerated [/ touch-down weight-bearing] was permitted. DVT prophylaxis was initiated. Physical therapy and early mobilization were ordered for postoperative day 1.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Right/Left *** hip fracture, *** [displaced/non-displaced]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left hip fracture CRIF, ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Spinal

INDICATIONS: .PTAGE-year-old .PTSEX with *** hip fracture after ***. Consent obtained.

FINDINGS: Reduction: *** on AP/lateral. Lag screw: center-center [/center-inferior AP, center-center lateral]. TAD <25 mm. No articular penetration.

PROCEDURE:
Supine on fracture table, traction, *** contralateral leg position. Closed reduction under fluoroscopy; ***. AP/lateral confirmed. *** cm incision proximal GT. Abductors split. Entry portal per implant spec. Ball-tipped wire, reamed to *** mm. *** × *** mm nail inserted. Lag screw guide: ***°, center-center FH, TAD <25 mm. Lag screw inserted. Distal interlock freehand. Set screw tightened. Final fluoro AP/lateral: alignment acceptable, no articular penetration. Closed in layers.

EBL: *** mL
COMPLICATIONS: None
DISPOSITION: WBAT/TDWB. DVT prophylaxis. PT POD 1.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Dynamic Hip Screw (DHS): Stable Intertrochanteric (CPT 27244)

For a stable two-part intertrochanteric fracture, a dynamic hip screw (DHS) was used (CPT 27244, plate/screw implant). A lateral approach to the proximal femur was made through a [8–10]-cm incision. The iliotibial band and vastus lateralis were incised. Under fluoroscopic guidance, the guidewire was placed center-inferior in AP view and center-center in lateral view at a [135°] angle. Tip-apex distance was measured and confirmed <25 mm. The guidewire was over-reamed. The [X]-mm × [X]-mm lag screw was inserted. A [2- to 4-hole] side plate was applied to the lateral femoral cortex and fixed with cortical screws. The dynamic design permits controlled impaction across the fracture. DHS is appropriate for stable fractures; cephalomedullary nailing (27245) is preferred for unstable, reverse obliquity, or subtrochanteric extension patterns.

Femoral Neck Fracture: Cannulated Screw Fixation (CPT 27235)

For a non-displaced [or minimally displaced] femoral neck fracture (Garden I/II) in a physiologically young patient, percutaneous cannulated screw fixation was performed (CPT 27235). Three [6.5-mm / 7.3-mm] partially-threaded cannulated screws were placed in an inverted triangle configuration under fluoroscopic guidance with all threads across the fracture. The inferior screw was placed along the calcar for rotational stability. All screws were confirmed to stop short of the subchondral bone. If open reduction was required, use 27236 instead of 27235.

Charting Tips
  • Document tip-apex distance (TAD) explicitly. TAD >25 mm is the strongest predictor of lag screw cutout, the most common implant failure mode. TAD is calculated as the sum of the distance from the tip of the lag screw to the apex of the femoral head in AP and lateral views, each corrected for radiographic magnification using the known lag screw diameter as calibration reference (Baumgaertner, JBJS 1995).
  • Document lag screw position in both AP and lateral views. Center-center in both planes is optimal. Center-inferior in AP (with center-center on lateral) is acceptable. Superior placement in AP view strongly correlates with cutout and should be documented as a recognized suboptimal position if unavoidable.
  • Document fracture classification. For femoral neck: Garden classification (I/II non-displaced, III/IV displaced) drives the implant decision and ICD-10 specificity. For intertrochanteric: AO/OTA stable (two-part) vs. unstable (comminution, reverse obliquity, subtrochanteric extension) determines implant selection — DHS for stable, cephalomedullary nail for unstable.
  • Document weight-bearing status and rationale. Hip fracture fixation is generally weight-bearing as tolerated (WBAT), as elderly patients cannot reliably comply with restricted weight-bearing. Document the rationale if weight-bearing is restricted.
Billing Tips
  • 27235 (percutaneous skeletal fixation of femoral neck fracture, 12.68 wRVU, 90-day global) and 27236 (open treatment of femoral neck fracture with internal fixation or prosthetic replacement, 17.17 wRVU, 90-day global) are standalone primary codes for femoral neck fractures. These are mutually exclusive — select based on whether the approach is percutaneous or open, not on implant type.
  • 27244 (intertrochanteric/peritrochanteric/subtrochanteric fracture ORIF with plate/screw implant, e.g., dynamic hip screw; 17.73 wRVU, 90-day global) and 27245 (same fracture pattern ORIF with intramedullary implant, e.g., cephalomedullary nail; 17.73 wRVU, 90-day global) are mutually exclusive standalone primary codes — select based on implant type used, not fracture classification. The wRVU is identical for both.
  • Hemiarthroplasty for displaced femoral neck fracture is coded 27236 (17.17 wRVU) — NOT 27125. CPT 27125 is for hemiarthroplasty performed for degenerative conditions (arthritis), not fracture. Using 27125 for fracture-indication hemiarthroplasty is a common, audited coding error. For primary total hip arthroplasty performed for an acute femoral neck fracture, use 27130 (19.11 wRVU). CPT 27132 (25.05 wRVU) is specifically for conversion of prior hip surgery to THA — not for primary THA on a fresh fracture in a patient without prior hip surgery.
  • 90-day global period: weight-bearing protocol management, physical therapy coordination, and routine radiographic follow-up are bundled. DVT prophylaxis management is clinical, not a separately billable procedure within the global.
  • ICD-10: S72.0xx (femoral neck fracture), S72.1xx (intertrochanteric/pertrochanteric fracture), S72.2xx (subtrochanteric fracture). Each requires laterality (1=right, 2=left, 9=unspecified) and 7th character (A=initial encounter for closed fracture, D=subsequent encounter, S=sequela). Document displaced (Garden III/IV) vs. non-displaced (Garden I/II) for femoral neck fractures to support specificity. Document stable vs. unstable (AO/OTA classification) for intertrochanteric fractures.

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