Differentiating Fracture Coding with Osteoporosis Present

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While working on the team for AHIMA’s Code-CheckTM Coding Question Service, I’ve noticed several questions related to providing clarification in ICD-10-CM for a fracture in a patient with known osteoporosis.

ICD-10-CM expands the code selection to more than 150 pathologic fracture codes. The codes for pathologic fractures with ­osteoporosis require a seventh character to indicate episode of care. Coding professionals will need additional details to capture the correct codes in ICD-10-CM.

The Centers for Medicare and Medicaid Services’ ICD-10-CM Official Guidelines for Coding and Reporting, FY 2016, defines osteoporosis in Chapter 13 as follows:

Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Therefore, site is not a component of the codes under category M81, Osteoporosis without current pathological fracture. The site codes under category M80, Osteoporosis with current pathological fracture, identify the site of the fracture, not the osteoporosis.

The guideline go on to describe the correct application of category M81, osteoporosis without pathological fracture, and category M80, osteoporosis with current pathological fracture:

1) Osteoporosis without pathological fracture

Category M81, Osteoporosis without current pathological fracture, is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past. For patients with a history of osteoporosis fractures, status code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81.

2) Osteoporosis with current pathological fracture

Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis 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, healthy bone.

I’ve been hearing of some confusion related to the statement, “A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis 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, healthy bone.”

Sometimes it is hard to determine what would not usually break a normal, healthy bone. So how do coders differentiate the two types of fractures?

When reviewing the record to determine the circumstances of the injury, a couple of examples comparing pathological fracture to traumatic fracture are as follows:

  • Pathological fracture is caused by disease. For example, fractures sustained in an activity that normally would not cause a fracture such as bending over to pick something up or walking up the stairs.
  • Traumatic fracture is caused by some type of accident. For example, fractures sustained in a motor vehicle accident or falling off of a roof.

Sometimes it’s quite obvious, as in the examples above. If it is not documented in the record and if the coding professional does not know if the fracture was pathologic or traumatic, then they won’t be able to select the correct codes.

If the provider does not document the type of fracture and it is not clear, we recommend querying the physician. Please refer to the Practice Brief “Guidelines for Achieving a Compliant Query Practice” for more guidance and multiple examples of cases in which a query in necessary.

When you do run into challenging cases, there are many helpful resources available to assist in answering your questions. To receive official ICD-10-CM and ICD-10-PCS coding advice, you can send questions to the American Hospital Association’s Coding Clinic. AHIMA’s Engage communities are a great place to ask coding advice from other coding professionals that may have encountered similar situations, and AHIMA’s Code-Check service provides expert coding advice as well. Don’t forget you can take advantage of these coding resources.

Gina Sanvik, MS, RHIA, AHIMA-approved ICD-10-CM/PCS Trainer, is director, coding and data standards, HIM practice excellence at AHIMA. In her role she provides technical expertise for the creation and review of AHIMA’s coding-related products such as webinars, Practice Briefs, educational courses, and articles. She also works with the AHIMA coding service product AHIMA CheckPoint™: Code-Check.

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