Radiology Coding Alert

Plus, remember that external cause codes are optional.

As a radiology coder, you can expect to see several medical reports with fracture diagnoses. Some of those cases may involve injuries that will test your ICD-10-CM guideline knowledge regarding traumatic and pathologic fractures.

Study the following procedure note and see if you can identify the correct codes for the encounter.

Examine This Radiologist’s Procedure Note

Facility: Outpatient radiology practice

Date of Procedure: 10/8/20XX

Chief complaint: The patient presents with severe pain in the left pelvic region, suspected to be due to a fracture.

History of present illness: The patient is a 75-year-old individual with a known history of age-related osteoporosis. The patient reports a sudden onset of severe left pelvic pain following a minor fall at home. No other injuries were reported.

Procedure:

1. Two-view X-ray of pelvis.

2. CT of pelvis without contrast and then with contrast media.

Findings:

1. Pelvic X-ray: An X-ray was ordered to assess for bone fractures. The patient was positioned appropriately, and AP and lateral X-ray views were taken, focusing on the pelvic region. The images showed abnormalities suggesting a fracture in the left pelvic region.

2. CT Scan: Due to the complexity of the pelvic region and to confirm the findings from the X-ray, CT scans were performed. The patient was positioned in the CT scanner and images were taken of the pelvic area without contrast, then contrast was administered, and additional images were captured. The scans provided a more detailed, cross-sectional

image of the body and confirmed the presence of a pathological fracture in the left pelvis.

Impression: The imaging scans confirm a pathological fracture of the left pelvis. The patient’s existing condition of age-related osteoporosis contributed to the fracture.

Pick the Procedure Codes

The radiology clinic performed two different exams. First, they performed two-view X-rays of the patient’s pelvis. After examining the images, the radiologist saw the need for additional imaging and requested a CT scan without, and then with, contrast media.

You’ll assign 72170 (Radiologic examination, pelvis; 1 or 2 views) to report the anteroposterior (AP) and lateral X-ray views of the patient’s pelvis. Next, you’ll assign 72194 (Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections) to report the CT scans.

The radiology clinic performed two separate imaging scans related to the same condition, but the radiologist required a CT scan after the X-rays to accurately evaluate the patient’s injury. You’ll append modifier 51 (Multiple procedures) to 72194 to indicate the second imaging scan was performed on the same day during the same encounter.

Identify the Correct Diagnosis Codes

You’ll then turn to the ICD-10-CM code set to assign the applicable diagnosis codes. The radiologist’s findings list a pathological fracture of the left pelvis as a result of age-related osteoporosis.

As of Oct. 1, 2023, the ICD-10-CM code set now contains age-related osteoporosis with a pathological fracture codes. Prior to the 2024 ICD-10-CM code set, “osteoporosis with pathological fracture of the pelvis was coded incorrectly, and not as specific as we would want. The condition was coded to fracture of femur, which is anatomically incorrect.,” said Jill Young, CEMC, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan, during AAPC’s “2024 ICD-10-CM Updates” webinar.

The 2024 ICD-10-CM Alphabetic Index offers two paths to the same osteoporosis-related fracture code:

• Fracture, pathological (pathologic) > due to > osteoporosis
• Osteoporosis (female) (male) > with current pathological fracture

Both paths direct you to M80.00- (Age-related osteoporosis with current pathological fracture, unspecified site). When you turn to the Tabular List to verify the code, you’ll find M80.0B- (Age-related osteoporosis with current pathological fracture, pelvis). This code subcategory requires 6th and 7th characters to complete the code. The 6th character specifies the laterality, and the 7th character specifies the type of encounter.

You’ll choose from the following 6th character options:

1 = Right pelvis

2 = Left pelvis

3 = Unspecified pelvis

You’ll then choose from the following 7th character options:

• A = Initial encounter for fracture
• D = Subsequent encounter for fracture with routine healing
• G = Subsequent encounter for fracture with delayed healing
• K = Subsequent encounter for fracture with nonunion
• P = Subsequent encounter for fracture with malunion
• S = Sequela

You would report M80.0B- “if the cause of the osteoporosis is due to the natural aging process or if the cause is not otherwise specified (NOS),” while you would report M80.8B- (Other osteoporosis with current pathological fracture, pelvis) “if the cause of the osteoporosis is for a reason other than the natural aging process, such as if it is due to drugs, disuse, following a postoophorectomy, due to postsurgical malabsorption, following a traumatic injury, or for another reason per the ICD-10-CM code set instructional notes,” says Taylor Berrena, COC, CPC, CPB, CRC, CPMA, CEMC, CFPC, CHONC, coder II at MD Anderson Cancer Center at Cooper in Yorktown, Virginia.

With this information in mind, you’ll assign M80.0B2A (Age-related osteoporosis with current pathological fracture, left pelvis, initial encounter for fracture) to report the radiologist’s findings.

Does a fall mean a traumatic fracture? The medical report documents the patient experienced a minor fall at home, so you might think the patient experienced a traumatic fracture. However, this would not be true in this case, as the patient had a documented case of osteoporosis.

According to the ICD-10-CM Official Guidelines, section I.C.13.d.2, “A code from 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.”

Next, depending on your individual payer preferences, you’ll assign an external causes code to document how the injury occurred. For this injury, you can assign W19.XXXA (Unspecified fall, initial encounter) to indicate the patient suffered the injury during a fall at home.

Currently, there isn’t a national requirement mandating ICD-10-CM external cause code reporting, and “[u]nless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer, reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity, is not required,” according to the Official Guidelines.

Wrap up Your Claim

In summary, you’ll assign the following codes for this encounter:

CPT®: 72170, 72194-51

ICD-10-CM: M80.0B2A, W19.XXXA