Orthopedic Coding Alert

Question: The orthopedist performs a level-three evaluation and management (E/M) service for a patient with osteoporosis. Notes indicate that the patient doesn't have a current pathological fracture, but did have an osteoporosis fracture of her right foot four years ago that has since healed. What ICD-10 codes should I choose for this patient's condition?

Montana Subscriber

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

On the claim, you'll report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) for the encounter.

First Dx: For a primary diagnosis, you'll append one of the following ICD-10 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 append Z87.310 (Personal history of (healed) osteoporosis fracture) to 99203 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."