Orthopedic Coding Alert

Turn to this category for age-related osteoporosis with current pathologic fracture.

Since ICD-10-CM offers so many codes for different types of fractures, it’s vital that you check the documentation and identify the specific kind of fracture. For example, when your provider diagnoses a patient with pathologic fracture, you should understand what different kinds of conditions cause pathologic fractures.

First, Define Pathologic Fractures for Clarity

FAQ 1: What is a pathologic fracture?

Answer: A pathologic fracture occurs when a bone breaks in an area that is weakened by another disease process. Causes of weakened bone include tumors, infection, and certain inherited bone disorders. If reporting a pathological fracture, it is absolutely necessary to make sure the documentation states the underlying cause of the disease.

A pathologic fracture usually occurs with normal activities. Patients may be doing very routine activities when their bone suddenly fractures or dislocates. The reason for a fracture is that the underlying disease process weakens the bone to the point where the bone is unable to perform its normal function.

Sift Through Different Pathologic Fracture Categories

FAQ 2: What are the pathologic fracture categories in ICD-10-CM?

Answer: ICD-10-CM has several different pathologic fracture categories. They are as follows:

• M80.0- (Age-related osteoporosis with current pathological fracture)
• M80.8- (Other osteoporosis with current pathological fracture)
• M84.4- (Pathological fracture, not elsewhere classified)
• M84.5- (Pathological fracture in neoplastic disease)
• M84.6- (Pathological fracture in other disease)

Pinpoint Correct Code for Age-Related Osteoporosis with Current Pathologic Fracture

FAQ 3: My provider documented that the patient has age-related osteoporosis with a current pathological fracture in their right foot. This is the initial encounter for the fracture. Which ICD-10-CM code should I report on my claim?

Answer: You should report M80.071A (Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture).

The ICD-10 Official Guidelines for Coding and Reporting identify osteoporosis as “a systemic condition, meaning that all bones of the musculoskeletal system are affected.”

You should only report codes from category M80- (Osteoporosis with current pathological fracture) for patients who have a current pathologic fracture at the time of the encounter, per the guidelines. The codes in this category identify the site of the patient’s fracture.

Caution: You should report a code from category M80-, not a traumatic fracture code, if a patient with known osteoporosis has a fracture. This is true even if the patient has a minor fall or trauma - but only if that fall or trauma would not have usually broken a normal, healthy bone.

Code Pathologic Fractures Due to Neoplasm Like This

FAQ 4: My provider documented a pathologic fracture in the patient’s left ankle due to a neoplasm. The neoplasm is of unspecified behavior. This was an initial encounter for treatment of the fracture. Which ICD-10-CM codes should I report on my claim?

Answer: You should report M84.572A (Pathological fracture in neoplastic disease, left ankle, initial encounter for fracture), followed by either D49.2- (Neoplasm of unspecified behavior of bone, soft tissue, and skin) or D49.89 (Neoplasm of unspecified behavior of other specified sites) on your claim. Check with your payer and/or provider to see which diagnosis they prefer.

Don’t miss: A note under category M84.5- also tells you to also code the underlying neoplasm.

ICD-10-CM guidelines: The guidelines give you very specific rules for reporting pathologic fractures due to neoplastic disease. They are as follows:

When the encounter is for a pathologic fracture due to a neoplasm and the focus of treatment is the fracture, you should report the appropriate code from subcategory M84.5-, followed by the code for the neoplasm.

If the focus of the treatment is the neoplasm with an associated pathological fracture, you should sequence the neoplasm code first, followed by the appropriate code from M84.5 for the pathologic fracture.

Take Heed of “Other Diseases” That Cause Pathologic Fractures

FAQ 5: My provider documented a fracture in that patient’s right ankle that is due to a bone cyst. This was an initial encounter. What ICD-10-CM code should I look to?

Answer: In this case, you should report M84.671A (Pathological fracture in other disease, right ankle, initial encounter for fracture) from the category for a pathologic fracture caused by “other diseases” — M84.6-. Some examples of “other diseases” that could cause pathologic fractures include osteogenesis imperfecta, bone cysts, fibrous dysplasia, Paget’s disease, osteomyelitis, and histiocytosis.

Documentation tips: When you report a code from category M84.6-, you must check the documentation for the underlying pathology and the specific diagnosis stating the pathologic fracture.