Radiology Coding Alert

M81.0 applies to senile, postmenopausal, involutional, and unspecified osteoporosis. 

The first step to coding low bone density is to distinguish between osteoporosis and osteopenia. The two are specific conditions and are different. There is not a real one-to-one match for codes in ICD-10. Here are details that will help you define definitive ICD-10 codes for these conditions. 

Differentiate Osteopenia From Osteoporosis

You are wrong if you assume osteopenia and osteoporosis to be the same. “Your physician gives a diagnosis of osteopenia when a person’s bone mineral density is lower than normal but not to the extent of osteoporosis,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Cartersville, GA. “Osteopenia and osteoporosis may lead to bone weakening and an increased risk of fractures.”

What is osteoporosis? Osteoporosis is essentially a bone disease caused by dropping estrogen levels in postmenopausal women. Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, and wrist.

What is osteopenia? Osteopenia means the patient’s bone mineral density is lower than normal. While osteopenia can be a risk factor or precursor for developing osteoporosis, all patients who have osteopenia do not develop osteoporosis. For osteopenia, the physician may recommend calcium supplements and weight bearing exercises.

Ascertain the Cause for Osteoporosis

To be able to submit the right code for osteoporosis, you need to determine what type of osteoporosis was documented by your physician.

ICD-9-CM Codes: Currently, you should report these conditions with the following codes:

• 733.00, Osteoporosis unspecified
• 733.01, Senile osteoporosis

ICD-10-CM Codes: However, these diagnoses change after October 1, 2015. The two ICD-9 codes, 733.00 and 733.01 map to the following code in ICD-10:

• M81.0, Age-related osteoporosis without current pathological fracture

When your physician does not document the cause of osteoporosis, you report code 733.02 (Idiopathic osteoporosis). This code maps to code M81.8 (Other osteoporosis without current pathological fracture) in ICD-10. 

When your physician documents disuse to be the main causative factor for osteoporosis, you report ICD-9 code 733.03 (Disuse osteoporosis). Like 733.02, the code 733.03 also maps to ICD-10 code M81.8.

For any other type of osteoporosis, for example, drug induced osteoporosis, you submit code 733.09 (Other osteoporosis). When ICD-10 goes into effect, this code maps to M81.8 and M81.6 (Localized osteoporosis [Lequesne]).

Translation: Once ICD-10 goes into effect, you’ll report M81.0 for senile osteoporosis (733.01). 

Check Multiple Options for Osteopenia

In ICD-9, you report code 733.90 (Disorder of bone and cartilage unspecified). In ICD-10, you will have multiple options. For 733.90, your osteopenia choices will expand to M85.8--, which requires 6 digits. The 5th digit will denote the anatomic site (e.g., thigh, forearm, shoulder, etc) while the 6th digit will denote the side of the body (e.g., right side). “Not only in ICD-10 do you need to know the exact anatomical location of the osteopenia diagnosis but the 6th digit specifies the location of the osteopenia as being right, left or unspecified,” Hembree says.

Caution: The ICD-10-CM Alphabetic index directly references the term “osteopenia” and lists those codes that you should assign. If you use the General Equivalency Mappings (GEMs) tools instead to pick the ICD-10 code, it will lead you instead to two incorrect codes: M89.9 (Disorder of bone, unspecified), or M94.9 (Disorder of cartilage, unspecified).

Dig Into Terminology for M81.0

For M81.0, you might see the following terminology:

• Involutional osteoporosis without current pathological fracture
• Osteoporosis NOS
• Postmenopausal osteoporosis without current pathological fracture
• Senile osteoporosis without current pathological fracture

For M85.--, the provider needs to document the part of the body that is affected by the osteoporosis, and well as which side is showing these changes. 

Here is how you will locate these codes in the Alphabetic Index:

Osteopenia M85.8-

- borderline M85.8-

Osteoporosis (female) (male) M81.0

- age-related M81.0
- postmenopausal M81.0

Disorder(of) —see also Disease

- bone M89.9
- - density and structure M85.9
- - - specified type NEC M85.8-
- - - - ankle M85.87-
- - - - foot M85.87-
- - - - forearm M85.83-
- - - - hand M85.84-
- - - - lower leg M85.86-
- - - - multiple sites M85.89
- - - - neck M85.88
- - - - rib M85.88
- - - - shoulder M85.81-
- - - - skull M85.88
- - - - thigh M85.85-
- - - - upper arm M85.82-
- - - - vertebra M85.88

Coder’s tips: Underneath the M81 category, you’ll see a note instructing you to “use additional code to identify: major osseous defect, if applicable (M89.7-); personal history of (healed) osteoporosis fracture, if applicable (Z87.310).” You also have an Excludes1 note forbidding you from reporting any M81 code for osteoporosis with a current pathological fracture (M80.-) or Sudeck’s atrophy (M89.0).