Neurology & Pain Management Coding Alert

Question: The PM specialist treated a patient with osteoporosis. The patient doesn’t have a current pathological fracture, but notes indicate that she did have an osteoporosis fracture of her right foot three years ago that has since healed. What ICD-10-CM codes should I choose for this patient’s condition?

Wisconsin Subscriber

Answer: You’ll need one diagnosis code for the patient’s current osteoporosis and another for her fracture history.

First Dx: For a primary diagnosis, you’ll append one of the following ICD-10-CM codes for the patient’s current osteoporosis:

• M81.0 — Age-related osteoporosis without current pathological fracture
• M81.6 — Localized osteoporosis (Lequesne)
• M81.8 — Other osteoporosis without current pathological fracture.

Second Dx: You’ll also need Z87.310 (Personal history of (healed) osteoporosis fracture) as a secondary diagnosis. As the instructions below M81.0 instruct coders, you should use an additional code to identify “personal history of (healed) osteoporosis fracture, if applicable.”