We are unsure how to report the following service.  The surgeon removed an infected total hip prosthesis and inserted a spacer (CPT code 27091), then placed the patient on IV antibiotics.   2 weeks after he put the spacer in, he had to take the patient to the OR again because the spacer was infected. He removed the spacer and re-inserted a new spacer at that time.
How do we code this second procedure?

There is no CPT code to describe this procedure.  While some may suggest 27030 Arthrotomy, hip, with drainage (eg, infection) or 27033Arthrotomy, hip, including exploration or removal of loose or foreign body, these codes do not describe the work you describe.  Report the unlisted procedure code 27299 Unlisted procedure, pelvis or hip joint with a modifier 58 since you are treating the original infected site.

Mary LeGrand, RN, MA, CCS-P, CPC
KarenZupko & Associates, Inc.