# Impending Fracture...



## BCrandall (Sep 23, 2009)

Anyone psychic out there? My Dr is, he's giving me a dx of "Left femur *impending* pathologic fracture". The patient has a lesion on his femur after a diagnosis of prostate cancer and the doc is putting in an intermedullary nail prior to radiation treatment. I'm using 27248 for the nailing, but I'm stuck on the ICD-9. Any hints or suggestions?


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## RebeccaWoodward* (Sep 23, 2009)

Shot in the dark but what about...

733.15 ?

*Plain English Description:*
A pathologic fracture is a break in a bone due to weakening by another disease or disorder, such as osteoporosis (see above). As another example, *a fracture at the site of a tumor is a very common *form of pathologic fracture. These fractures are classified according to the site where they occur:


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## BCrandall (Sep 23, 2009)

I thought about that one, but there's no fracture in the op note. I guess it's a pre-emptive stabilization, but no diagnosis in the cross coder works with the nailing code...


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## RebeccaWoodward* (Sep 23, 2009)

Boy...you've gotta good one.  Is there mention of any bone loss?  Osteolysis? *Osteolysis* refers to an active resorption or dissolution of bone tissue as part of an ongoing disease process

731.3  ?

Major osseous defects are the consequence of extensive amounts of bone loss. This kind of significant bone loss most commonly results from the breakdown of bone around a previous prosthetic joint replacement, necessitating revision surgery. Bone loss, or osteolysis, also occurs from osteomyelitis, osteonecrosis, *neoplastic growth*, severe osteoporosis, and pathological fractures[MDash]with or without previous joint replacement. Major osseous defects caused by these factors are clinically significant because the bone into which a joint implant must be placed to repair the defect is too weak to support the prosthesis without structural bone repair. Knowledge of these bone defects and contributing factors help determine diagnosis and treatment as well as predict surgical outcomes. Primary or revision joint replacement must often be done together with morcelized or structural bone grafting and additional mechanical support for the graft such as wires, cables, cages, wedges, screws, etc. The most common area affected is the hip joint, followed by the knee. Code the underlying disease or disorder first, when it is known to have caused the major osseous defects.

Clarifying Terms:
Code first underlying disease, if known, such as:
   aseptic necrosis (733.40-733.49)
*malignant neoplasm of bone (170.0-170.9)* 
 osteomyelitis (730.00- 730.29)
 osteoporosis (733.00-733.09)
   peri-prosthetic osteolysis (996.45)


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## BCrandall (Sep 23, 2009)

rebeccawoodward said:


> Boy...you've gotta good one.  Is there mention of any bone loss?  Osteolysis? *Osteolysis* refers to an active resorption or dissolution of bone tissue as part of an ongoing disease process
> 
> 731.3  ?
> 
> ...



Boy do I have a good one!

No mention of anything but the impending fracture, prostate cancer history and the femur lesion. I'm stuck!


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## Anna Weaver (Sep 23, 2009)

*impending*

Could you use the prophylactic measures I wonder? V07.8?


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## BCrandall (Sep 23, 2009)

Anna Weaver said:


> Could you use the prophylactic measures I wonder? V07.8?


I've been looking thru the v codes, but I'm not finding anything that matches. I need a better vocabulary!


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## BCrandall (Sep 23, 2009)

What does everybody think about 27187 with 239.2 and 731.36? Here's the op note...

Postoperative Diagnosis: Left femur impending pathologic fracture.


Procedures Performed: 1. Left femur intramedullary nailing prophylactically. 2. Intraoperative biopsy of the intramedullary reaming.


The right lower extremity was prepped and draped in a sterile fashion. Standard longitudinal incision made over the proximal aspect of the greater trochanter. Dissection carried down to the fascial band. Start hole over the greater troch was performed using a guide pin confirmed by AP and lateral fluoroscopy. Initiating reamer placed over the guide wire and reamed down to the level of lesser troch. The guide wire was then placed into the intramedullary canal and advanced distally to the level of the distal physeal scar of the femur. Then, the canal was reamed in sequential fashion up to a 12.5-mm diameter. The reaming was sent off for frozen section with the pathologist. The decision was then made to place an 11.5 x 42-cm nail from Smith and Matthew Recon nail. This was advanced over the guide wire in standard technique. The guide wire was removed. The placement of the nail confirmed by AP and lateral fluoroscopy. Then one proximal interlocking screw and one distal interlocking screw was placed in standard technique. The final placement of the hardware was confirmed by AP and lateral fluoroscopy. The wound was then copiously irrigated. Deep fascial closure using 0 Vicryl, skin closure using 2-0 Vicryl and staples. Sterile dressing applied. The patient was then awakened and taken to PACU in stable condition. The patient tolerated the procedure well. All instrument counts, needles counts were correct. Patient will be up as tolerated. Weightbear as tolerated.


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## RebeccaWoodward* (Sep 23, 2009)

731.36?  I can't locate this ICD-9.....


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## BCrandall (Sep 23, 2009)

rebeccawoodward said:


> 731.36?  I can't locate this ICD-9.....



Sorry, dyslexic typing...I meant 731.3 like you suggested!

Maybe the pre-op history would help...


History: The patient is a 71-year-old retired gentleman who by and large has enjoyed good health all his life. He has mild hypertension and hypercholesterolemia. Several years ago he was discovered to have prostate cancer and he was treated with a prostatectomy and I suspect some testosterone suppressive therapy. He was doing well until a routine check of his PSA found it to be elevated recently and further investigations showed lesions in his spine and femur. He is being referred for stabilization of his femur with an intramedullary nail prior to starting radiation therapy.


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## RebeccaWoodward* (Sep 23, 2009)

I like it Bruce...Your ICD-9 codes support the CPT code as well.


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## BCrandall (Sep 23, 2009)

I'm going to go with that...I'm spent! Thanks for your input Rebecca. Are you coming to the Coding Conference up here next week?


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## RebeccaWoodward* (Sep 23, 2009)

Hmmm...I'm not sure I knew about it...Where is it located? I would love some details...You can email me off line if you prefer...I'll send you a PM..


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## jmkitchen (Sep 23, 2009)

Since this is not a 'current' fracture, but rather a prophylactic measure, you may want to rethink your CPT code.  Look at 27187- "prophylactic treatment" (nailing, pinning, plating or wiring).  Then I think you could use the primary and secondary malignant neoplasm codes and they would pass your cross-coder.


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## RebeccaWoodward* (Sep 24, 2009)

jmkitchen said:


> Since this is not a 'current' fracture, but rather a prophylactic measure, you may want to rethink your CPT code.  Look at 27187- "prophylactic treatment" (nailing, pinning, plating or wiring).  Then I think you could use the primary and secondary malignant neoplasm codes and they would pass your cross-coder.




Bruce is using 27187.  Look at his later response.


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## BCrandall (Sep 24, 2009)

The problem is in the dictation, there's no mention of neoplasms, just lesions. Since this was prophaltic treatment the cross coder assumes there's already a current neoplasm/cancer diagnosis made, which may be but it's not documented for this service.


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## ehaff (Apr 25, 2013)

V07.8 would be the appropriate diagnosis for admission for impending pathologic fracture - prophylactic rodding.


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