Home Health ICD-9/ICD-10 Alert

Question:  I’ve heard that when a patient who has osteoporosis suffers a fracture we should code for the fracture as a pathological fracture if the fall or trauma would not usually break a normal, healthy bone. But how can I determine what would usually break a normal, healthy bone?

Maryland Subscriber

Answer:  New guidelines for coding osteoporosis in ICD-10 will help clarify how to code for the types of patients you describe. In the instructions for Chapter 13, the ICD-10-CM Draft Official Guidelines for Coding and Reporting state:

“Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of the encounter. … A code for 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.”

When a patient with osteoporosis suffers a fall that results in a fracture, you would report a pathologic fracture code. But if the fracture occurred due to a motor vehicle accident, a trauma fracture code would be more appropriate. However, if a patient with osteoporosis fractures a bone through the simple act of bending over or picking something up, the fracture is most likely pathologic, since these activities wouldn’t usually result in breaking a normal healthy bone. Likewise, falling from a standing height or less wouldn’t normally cause a fracture on a normal healthy bone.

Bottom line: If you have any questions about whether your patient has a pathologic fracture, be sure to query the physician.

Coding example: Your patient has osteoporosis. She recently fell off her chair at the kitchen table and suffered a pathologic lumbar compression fracture. Your agency is providing aftercare. In ICD-9, you would code for the patient as follows

You’re providing aftercare for your patient’s pathologic fracture, so V54.27 is the principal diagnosis. Across from the M1020a diagnosis, in M1024, you’ll list the fracture diagnosis (733.13). You’re unlikely to earn case mix points for this Ortho 2 diagnosis, but you cannot report it in M1020/M1022.

Next, list 733.00 to indicate that your patient has osteoporosis. This is an unspecified code — if you’re able to gather more details, you can list a more specific code such as 733.01 (Senile osteoporosis).

The E code further describing your patient’s fall is optional, but it does give greater detail about your patient’s condition.

Tip: If your patient has previously suffered other pathologic fractures, you may want to also list V13.51 (Personal history of pathologic fracture).

In ICD-10 for this patient, you’ll list:

• M1021a: M80.08xD (Age-related osteoporosis with current pathological fracture, vertebrae; subsequent encounter for fracture with routine healing) and
• M1022b: W07.xxxD (Fall from chair; subsequent encounter).

In ICD-10, one code indicates that your patient has a pathologic fracture due to osteoporosis and that your agency is providing subsequent care. Although the medical record doesn’t specify that this patient has senile osteoporosis, the M80 category is the default for a pathologic fracture due to osteoporosis not otherwise specified

The external cause code is still optional in ICD-10, but continues to provide additional detail.

If your patient has a history of pathologic fractures due to osteoporosis, in ICD-10 you can also list Z87.310 (Personal history of [healed] osteoporosis fracture).