A061. Hip Fracture — Acute Inpatient Management of Closed Proximal Femur Fractures
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Governs acute inpatient admission, level of care, continued stay, and discharge readiness for Curative commercial members with closed proximal femur fractures treated surgically or, in selected cases, nonoperatively.
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Policy Summary
PayerCurative
PolicyA061. Hip Fracture — Acute Inpatient Management of Closed Proximal Femur Fractures
Policy CodePolicy CHP-IP-2026-061
Change TypeNo material clinical or coverage change
Effective DateN/A
Next Review DateN/A
Key ActionComplete continued-stay review every 24 hours and document at least one qualifying ongoing hospital-level need.
No material clinical or coverage changes in this revision.
24–48 hoursSurgery window
3–5 daysUncomplicated stay
8 g/dLTransfusion threshold
24 hoursReview interval
3Care levels
8Documentation categories
Acute Inpatient Coverage Criteria
Initial inpatient admission
Covered when ALL of the following are met:
Acute inpatient admission
At least one clinical severity finding
Qualifying severity
Proximal femur fracture confirmed on radiograph, CT, or MRI.
Occult fracture confirmed on MRI or CT after negative radiographs in a member unable to bear weight.
Inability to bear weight or transfer safely, with clinical findings of hip fracture pending imaging confirmation.
Hemoglobin below 10 g/dL, or a drop of 2 g/dL or more, related to fracture blood loss.<10 g/dL or a drop of ≥2 g/dL
Delirium, rhabdomyolysis, or acute kidney injury after a long lie.
At least one hospital-level service required
Surgical fixation or arthroplasty planned within 24 to 48 hours of admission.Within 24–48 hours of admission
Preoperative medical optimization requiring inpatient monitoring, including anticoagulant reversal, correction of electrolytes, or management of decompensated heart failure or arrhythmia.
Preoperative regional nerve block and multimodal analgesia with monitoring.
Nonoperative management requiring IV analgesia or skilled nursing interventions not available at a lower level for the first 24 to 72 hours, such as for a nonambulatory member with a stable impacted femoral neck fracture and high operative risk.
Observation or outpatient management
Observation or outpatient management is appropriate when ANY of the following applies and no inpatient admission criterion is met:
Lower level of care
Hip pain after a fall with negative radiographs in a member who can bear weight, while awaiting MRI to exclude occult fracture, generally under 24 hours.
Isolated nondisplaced greater trochanter fracture with ability to ambulate and safe home support.
Nonoperative care of a stable impacted femoral neck fracture in an ambulatory member with adequate pain control on oral analgesics.
Intensive care unit
ICU care is appropriate when ANY of the following is present:
ICU level of care
Hemodynamic instability requiring vasopressors or hemorrhagic shock.
Respiratory failure, fat embolism syndrome, or massive pulmonary embolism.
Acute coronary syndrome, unstable arrhythmia, or decompensated heart failure requiring IV vasoactive therapy.
Bone cement implantation syndrome or another intraoperative event requiring postoperative critical care.
Step-down or intermediate care
Step-down or intermediate care is appropriate when ANY of the following is present:
Intermediate care
Need for continuous cardiac monitoring perioperatively, including for a new arrhythmia, troponin elevation, or high-risk cardiac disease.
Severe delirium requiring frequent reassessment and close nursing observation.
Supplemental oxygen above 4 L/min or noninvasive ventilation for obstructive sleep apnea or pulmonary disease after surgery.>4 L/min oxygen
Medical-surgical level of care
A medical-surgical orthopedic unit is appropriate when ANY of the following is present:
Preoperative and postoperative care for a hemodynamically stable member.
Physical and occupational therapy, VTE prophylaxis, and multimodal analgesia after surgery.
Mild delirium managed with nonpharmacologic measures.
Discharge readiness
Discharge from acute care is appropriate when ALL of the following are met:
Hemodynamically stable; hemoglobin stable for 24 hours without transfusion, or transfusion threshold criteria are not met.Hemoglobin stable for 24 hours
Pain controlled on oral analgesics sufficient to participate in therapy.
Mobilized with physical therapy, at minimum a bed-to-chair transfer, with weight bearing as allowed by the surgeon.
Wound has no signs of infection or expanding hematoma; voiding and bowel function are adequate.
Delirium is resolved or improving and does not require acute medical intervention.
Continued-stay criteria
Continued stay is medically necessary when ANY of the following is documented; review every 24 hours:
Awaiting surgery within the 24-to-48-hour window, or medical optimization is actively underway with a documented reason for delay.
Postoperative day 0 to 2 with daily therapy and monitoring.
Hemoglobin below 8 g/dL or symptomatic anemia requiring transfusion, or ongoing bleeding.Hemoglobin <8 g/dL or symptomatic anemia
Delirium, pneumonia, urinary retention with infection, acute kidney injury, venous thromboembolism, or a cardiac complication requiring hospital-level treatment.
Pain is not controlled on oral analgesics and prevents transfer or mobilization.
Expected length of stay and extended-stay review
The expected length of stay is a planning benchmark. Extended-stay review applies when ANY qualifying trigger is present, with review every 24 hours.
Extended-stay triggers
Surgery is delayed for a documented correctable medical condition.
Postoperative delirium.
Pneumonia.
Venous thromboembolism.
Cardiac event.
Surgical-site infection.
Open fractures are outside the scope of this policy and are addressed under Policy A065.
Femoral shaft fractures are outside the scope of this policy and are addressed under Policy A068.
Elective hip arthroplasty is outside the scope of this policy and is addressed in Section D.
Post-acute placement in an inpatient rehabilitation facility or skilled nursing facility is determined under the applicable post-acute policy.
The absence of a criterion addressing a service is not, by itself, a basis for an adverse determination. The request must be reviewed by a physician applying generally accepted standards of medical practice.
A continued acute stay solely while awaiting a skilled nursing or rehabilitation bed after acute-care discharge readiness criteria are met does not meet medical-necessity criteria. The case should proceed through physician review and discharge planning; authorized days must not be denied retroactively.
Delaying hip fracture surgery for routine preoperative testing, such as echocardiography or stress testing, in a member without active cardiac conditions does not meet criteria. Surgery is expected within 24 to 48 hours of admission when medically appropriate.
Continued stay for a routine transfusion in an asymptomatic member with hemoglobin 8 g/dL or higher does not meet criteria under the policy's restrictive transfusion approach.
Inpatient admission for hip pain after a fall with negative imaging and preserved ability to bear weight does not meet criteria; outpatient or observation management is appropriate.
Continued inpatient stay for a routine transfusion in an asymptomatic postoperative hip fracture patient with hemoglobin above the 8 g/dL threshold is not supported.
Applicable Coding and Planning Thresholds
ICD-10-CM Femoral Neck and Head FracturesICD-10
S72.001A
Femoral neck and head fractures
S72.002A
Femoral neck and head fractures
S72.009A
Femoral neck and head fractures
S72.011A
Femoral neck and head fractures
S72.012A
Femoral neck and head fractures
S72.019A
Femoral neck and head fractures
S72.021A
Femoral neck and head fractures
S72.022A
Femoral neck and head fractures
S72.023A
Femoral neck and head fractures
S72.024A
Femoral neck and head fractures
1–10 of 36
1/4
ICD-10-CM Trochanteric FracturesICD-10
S72.101A
Trochanteric fractures
S72.102A
Trochanteric fractures
S72.109A
Trochanteric fractures
S72.111A
Trochanteric fractures
S72.112A
Trochanteric fractures
S72.113A
Trochanteric fractures
S72.114A
Trochanteric fractures
S72.115A
Trochanteric fractures
S72.116A
Trochanteric fractures
S72.121A
Trochanteric fractures
1–10 of 27
1/3
ICD-10-CM Subtrochanteric FracturesICD-10
S72.21XA
Subtrochanteric fractures
S72.22XA
Subtrochanteric fractures
S72.23XA
Subtrochanteric fractures
S72.24XA
Subtrochanteric fractures
S72.25XA
Subtrochanteric fractures
S72.26XA
Subtrochanteric fractures
MS-DRGRevenue
480
MS-DRG
481
MS-DRG
482
MS-DRG
521
MS-DRG
522
MS-DRG
469
MS-DRG
470
MS-DRG
535
MS-DRG
536
MS-DRG
Revenue CodesRevenue
0120
Revenue code
0250
Revenue code
0270
Revenue code
0278
Revenue code
0300
Revenue code
0320
Revenue code
0360
Revenue code
0370
Revenue code
0420
Revenue code
0430
Revenue code
1–10 of 11
1/2
Applicable CodesRevenue
0300
0320
0360
0370
0420
0430
0710
Hemoglobin Related to Fracture Blood Loss
Hemoglobin thresholdBelow 10 g/dL
Qualifying hemoglobin changeA drop of 2 g/dL or more
Clinical contextRelated to fracture blood loss
Postoperative Transfusion Threshold
Hemoglobin thresholdBelow 8 g/dL
Alternative indicationSymptomatic anemia requiring transfusion
Provider Documentation and Review Actions
Documentation Required
Initial Inpatient Admission
Approve acute inpatient admission only when both are documented: at least one clinical-severity finding and at least one hospital-level service requirement.
Clinical severity: proximal femur fracture confirmed by radiograph, CT, or MRI; occult fracture on MRI/CT after negative radiographs with inability to bear weight; inability to bear weight or transfer safely with clinical findings pending imaging; hemoglobin <10 g/dL or a fracture-related drop of ≥2 g/dL; delirium (positive CAM or equivalent), rhabdomyolysis, or acute kidney injury after a long lie.
Hospital-level service: fixation or arthroplasty planned within 24–48 hours; inpatient medical optimization such as anticoagulant reversal, electrolyte correction, or management of decompensated heart failure/arrhythmia; monitored preoperative nerve block and multimodal analgesia; or nonoperative care requiring IV analgesia or skilled nursing unavailable at a lower level for the first 24–72 hours.
Documentation Required
Daily Continued-Stay Review
Review medical necessity every 24 hours and document at least one ongoing hospital-level need for each continued-stay day.
Clinical Background
Hip fracture in older adults is associated with substantial morbidity and one-year mortality. The policy supports timely surgery within 24 to 48 hours of admission, along with multimodal analgesia, VTE prophylaxis, interdisciplinary care, early mobilization, delirium screening, and secondary fracture prevention to support better outcomes.
Definitions and Planning Terms
Proximal Femur (Hip) Fracture
Included anatomyFemoral head or neck; intertrochanteric (pertrochanteric) region; or subtrochanteric region
Subtrochanteric boundaryWithin about 5 cm below the lesser trochanter
Policy termProximal femur (hip) fracture
Medically Optimized for Surgery
DefinitionCorrectable conditions have been addressed so surgery can proceed within 24 to 48 hours of admission
Examples of conditionsAnticoagulation, volume depletion, electrolyte disorders, decompensated heart failure, or active arrhythmia
Optimization concept
Policy Summary
PayerCurative
PolicyA061. Hip Fracture — Acute Inpatient Management of Closed Proximal Femur Fractures
Policy CodePolicy CHP-IP-2026-061
Change TypeNo material clinical or coverage change
Effective DateN/A
Next Review DateN/A
Key ActionComplete continued-stay review every 24 hours and document at least one qualifying ongoing hospital-level need.
A VTE prophylaxis plan for the post-discharge period is documented.
Discharge destination is confirmed—home with services, skilled nursing, or inpatient rehabilitation under the applicable post-acute policy—with secondary fracture prevention, including an osteoporosis evaluation and treatment plan, and a falls assessment documented.
A wound complication requires IV antibiotics or return to the operating room.
Dislocation.
Periprosthetic fracture.
Anemia requiring repeated transfusion.
Continued-stay contextMay support continued stay when transfusion is required or bleeding is ongoing
Expected Uncomplicated Length of Stay
Expected uncomplicated stay3 to 5 days
Benchmark beginsFrom admission
Coverage applicationPlanning benchmark only; not a limit on covered days
Postoperative Oxygen Threshold
Postoperative oxygen thresholdAbove 4 L/min
Level of careStep-down or intermediate care may be appropriate
Alternative respiratory supportNoninvasive ventilation for obstructive sleep apnea or pulmonary disease after surgery
Hip Fracture Surgery Timing
Expected surgery windowWithin 24 to 48 hours of admission
Applicable proceduresSurgical fixation or arthroplasty
Later surgeryRequires a documented reason for the delay
Postoperative Transfusion Threshold
Maximum thresholdNo higher than 8 g/dL
Patient groupAsymptomatic postoperative hip fracture patients
Stay above thresholdContinued inpatient stay for routine transfusion above 8 g/dL is not supported
Awaiting surgery within the 24–48-hour window, or active medical optimization with a documented reason for delay.
Postoperative day 0–2 with daily therapy and monitoring.
Hemoglobin <8 g/dL, symptomatic anemia requiring transfusion, or ongoing bleeding.
Pain uncontrolled by oral analgesics and preventing transfer or mobilization, or a wound complication requiring IV antibiotics or return to the operating room.
Documentation Required
Discharge Authorization
Authorize discharge from acute care only when all readiness criteria are documented.
Hemodynamically stable; hemoglobin stable for 24 hours without transfusion or transfusion-threshold criteria not met.
Pain controlled with oral analgesics sufficient for therapy participation; minimum bed-to-chair transfer completed with physical therapy and weight bearing as allowed.
Wound without infection or expanding hematoma; voiding and bowel function adequate.
Delirium resolved or improving without need for acute medical intervention.
Submit the injury and baseline context needed to evaluate severity, treatment needs, and discharge planning.
Mechanism of injury.
Pre-fracture functional status, including baseline ambulation and transfer ability.
Living situation and available home support.
Documentation Required
Fracture Imaging and Classification
Include the imaging report and the fracture classification used for treatment planning.
Document whether a femoral neck fracture is displaced or nondisplaced.
Classify an intertrochanteric fracture as stable or unstable and identify subtrochanteric fractures.
For suspected occult fracture after negative radiographs, include MRI or CT findings and the member’s ability to bear weight.
Documentation Required
Admission and Surgery Timing
Document admission and operative timing and explain any surgery occurring beyond the expected 24–48-hour window.
Record the time of hospital admission and the time of surgery.
State the clinical reason for any delay beyond 24 hours, including active medical optimization or another documented hospital-level need.
Documentation Required
Operative and Analgesic Services
Document the operative and analgesic services delivered or planned during the acute stay.
Anesthesia type and preoperative regional nerve block.
Multimodal analgesia and required monitoring.
Implant type.
Tranexamic acid use.
Documentation Required
Anemia and Transfusion
Provide laboratory trends and the clinical rationale for any transfusion or ongoing inpatient monitoring.
Hemoglobin trend, including the baseline and subsequent decline.
Transfusion indication, symptoms, active bleeding, and response.
Document that asymptomatic routine transfusion at hemoglobin ≥8 g/dL does not support continued inpatient stay.
Documentation Required
Delirium Monitoring
Record an objective delirium screening result every day, including CAM or an equivalent validated screen.
Document the daily result as positive, negative, resolved, or improving.
Explain any delirium-related monitoring or acute treatment supporting continued stay.
Documentation Required
Therapy and Mobility
Include therapy documentation showing the member’s current mobility and transfer level.
Record bed mobility, transfers, ambulation, and weight-bearing status as allowed by the surgeon.
Document whether pain, delirium, or another acute condition prevents safe mobilization.
Documentation Required
Discharge and Prevention Planning
Document the complete discharge and secondary-prevention plan before acute-care discharge.
VTE prophylaxis plan for the post-discharge period.
Osteoporosis evaluation and treatment plan.
Falls assessment and prevention plan.
Confirmed destination: home with services, skilled nursing, or inpatient rehabilitation under the applicable post-acute policy.
Documentation Required
Document Delayed Surgery
When surgery occurs later than the expected 24–48-hour window, document the specific clinical reason for the delay and the hospital-level care provided while awaiting surgery.
Record active medical optimization such as anticoagulant reversal, electrolyte correction, or treatment of decompensated heart failure or arrhythmia.
Routine preoperative testing alone is not a supported reason for avoidable delay in a member without active cardiac disease.
Unsupported block type: denial_risk
Unsupported block type: denial_risk
Unsupported block type: denial_risk
Unsupported block type: denial_risk
Unsupported block type: denial_risk
Medical issues are addressed sufficiently for timely surgery
Expected Length of Stay
DefinitionA planning benchmark for an uncomplicated course
Expected duration3 to 5 days from admission
Coverage limitationNot a limit on covered days
Confusion Assessment Method (CAM)
InstrumentConfusion Assessment Method (CAM)
PurposeValidated delirium screening
Policy useSupports objective continued-stay and discharge criteria
GMLOS
MeaningGeometric mean length of stay benchmark for expected inpatient length of stay
Benchmark yearCMS FY2027
Coverage applicationPlanning benchmark only; not a limit on covered days