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Official Description

Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc);

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 27258 refers to the open treatment of spontaneous hip dislocation, which can occur due to developmental dysplasia of the hip (DDH). This condition may arise from congenital malformations of the hip joint or develop during growth, impacting the osseous structures, joint capsule, and surrounding soft tissues. The procedure involves a surgical intervention where a skin incision is made on the medial aspect of the groin to access the hip joint. During the operation, the adductor tendon is exposed and incised, allowing for the release of other soft tissue structures as necessary to facilitate the reduction of the dislocated femoral head back into the acetabulum. The goal of this procedure is to restore proper alignment and function of the hip joint. After repositioning the femoral head, the surgical incisions are closed, and a splint or hip spica cast is applied to maintain the hip in an abducted position, ensuring stability during the recovery process. This procedure may also involve additional techniques such as tenotomy, which is the surgical cutting of a tendon, to achieve optimal results in the treatment of the dislocation.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The open treatment of spontaneous hip dislocation (CPT® Code 27258) is indicated for the following conditions:

  • Developmental Dysplasia of the Hip (DDH) - A condition where the hip joint is improperly formed, leading to dislocation.
  • Congenital Malformation - Structural abnormalities present at birth that can result in hip dislocation.
  • Pathological Dislocation - Dislocation that occurs due to underlying disease processes affecting the hip joint.

2. Procedure

The procedure for the open treatment of spontaneous hip dislocation involves several critical steps:

  • Step 1: Skin Incision A skin incision is made on the medial aspect of the groin to provide access to the hip joint. This incision is strategically placed to minimize damage to surrounding tissues and facilitate the surgical approach.
  • Step 2: Exposure of the Adductor Tendon Once the incision is made, the adductor tendon is carefully exposed. This step is crucial as it allows the surgeon to access the structures that may be contributing to the dislocation.
  • Step 3: Tenotomy and Soft Tissue Release The adductor tendon is incised, and any other necessary soft tissue structures are released. This release is essential to allow for the proper reduction of the dislocated femoral head.
  • Step 4: Repositioning the Femoral Head The femoral head is then repositioned within the acetabulum, effectively reducing the dislocation. This step restores the normal anatomy of the hip joint.
  • Step 5: Closure of Incisions After the femoral head is successfully reduced, the surgical incisions are closed in layers to promote healing and minimize scarring.
  • Step 6: Application of Splint or Hip Spica Cast Finally, a splint or hip spica cast is applied to maintain the hip in an abducted position, ensuring stability and support during the recovery phase.

3. Post-Procedure

Post-procedure care following the open treatment of spontaneous hip dislocation includes monitoring for any signs of complications, such as infection or improper healing. Patients are typically advised to limit movement and weight-bearing activities to allow for proper recovery. The application of a hip spica cast helps maintain the hip in the correct position during the healing process. Follow-up appointments are essential to assess the healing of the hip joint and to determine when physical therapy or rehabilitation can begin to restore function and mobility.

Short Descr TREAT HIP DISLOCATION
Medium Descr OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM
Long Descr Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc);
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62) 1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Inpatient Procedures, not paid under OPPS
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P3D - Major procedure, orthopedic - other
MUE 1
CCS Clinical Classification 146 - Treatment, fracture or dislocation of hip and femur
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
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2010-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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