Radiology Coding Alert

Question: A 75-year-old patient with a history of osteoporosis presented to a radiology practice with complaints of severe left heel pain. The radiologist captured lateral and anteroposterior (AP) X-ray views of the patient’s heel and interpreted the images. The provider documented their findings as a stress fracture of the left calcaneus due to osteoporosis.

What codes will I assign to report the encounter?

Virginia Subscriber

Answer: Starting with the procedure, you’ll assign 73650 (Radiologic examination; calcaneus, minimum of 2 views) to report the X-rays. The radiologist captured two views — AP and lateral — of the patient’s heel. The calcaneus is the large bone that makes up the heel and is one of the largest tarsal bones in the foot.

Some coders may be tempted to report 73620 (Radiologic examination, foot; 2 views) because of the word “foot” in the code descriptor, but this is incorrect as 73650 is specifically designated for X-rays of the heel.

Next, you’ll turn to the diagnosis codes for the encounter. The radiologist listed left calcaneus stress fracture due to osteoporosis in the findings. ICD-10-CM Official Guidelines, section I.C.13.d.2, covers osteoporosis with a current pathological fracture. The guideline instructs you to use category M80.- (Osteoporosis with current pathological fracture) for patients who have a current pathological fracture at the time of the encounter. In that case the appropriate M80.- code is 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.”

With this guidance in mind, you’ll assign M80.072A (Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture) with the 7th character A indicating the patient is seeking active care for the injury.