Wiki Peri-Prosthetic Fractures

[max21998@aol.com]

Hi,

Need some clarification on Peri- Prosthetic Fx's. We are getting insurance push back on the M97. code. They want them recognized as a Traumatic Fx (S..).Does anyone have any information as why the M code was chosen over the Traumatic (S) code as per the ICD 10 Book? As we know these types of Fx's can result from an injury. We are looking for explanations.

Thank you for your time.

 

[meghanhannus]

The issuce might be the DX code Sequencing for Peri-Prosthetic Fracture

Hello max21998@aol.com,

If the periprosthetic fracture is traumatic or pathological than you are to code first by site of the fracture(a DX from the S category), second a code from the M97 category (or M87 category or other supportive category if pathological) and third the appropriate external cause code if applicable. I would recommend querying the provider for any missing information or unclear diagnosis.


M. Hannus, CPC, CPMA, CRC

 

[max21998@aol.com]

Hello max21998@aol.com,

If the periprosthetic fracture is traumatic or pathological than you are to code first by site of the fracture(a DX from the S category), second a code from the M97 category (or M87 category or other supportive category if pathological) and third the appropriate external cause code if applicable. I would recommend querying the provider for any missing information or unclear diagnosis.


M. Hannus, CPC, CPMA, CRC

Thank you for the response. By coding the applicable type (traumatic or pathological) 1st, the M97 code 2nd, the book does not direct us to Code Additional. Just curious were you found this information.

 

[mitchellde]

I am questioning that as well. You would not use an S code if it were a pathologic fracture and if it were a new traumatic fracture you would not use the M97. perhaps the payer is wanting to know how the fracture happened .. in that was it due to a fall or was it due to a complication of the prosthesis, or perhaps it is simply due to strenuous movements (X50). so you may need a complication code or you may need to use an external cause code with the M97 as explanation. can you perhaps post the part of the note regarding the fracture

 

[meghanhannus]

Thank you for the response. By coding the applicable type (traumatic or pathological) 1st, the M97 code 2nd, the book does not direct us to Code Additional. Just curious were you found this information.

The AHA coding clinic 2016:

Periprosthetic fractures occur as a result of trauma or pathological conditions. A code for any underlying condition as well as a code for the specific type of fracture (traumatic or pathological)
should also be assigned. If the reason for admission/encounter is the fracture, the specific type of fracture (traumatic or pathological) should be sequenced first and the periprosthetic fracture
code should be sequenced as a secondary diagnosis code.

 

[mitchellde]

OK , However in response you indicated to use an S code if the fracture were traumatic or pathologic which would not be correct. so if there was a trauma incident that caused the fracture yes an S code. if it were pathologic the you need the M80 code , but if it is a complication then you need an complication T code. There are several different answers that could be correct. I was confused at to your answer regarding using the S code if the fracture was either trauma or pathologic.

 

[meghanhannus]

OK , However in response you indicated to use an S code if the fracture were traumatic or pathologic which would not be correct. so if there was a trauma incident that caused the fracture yes an S code. if it were pathologic the you need the M80 code , but if it is a complication then you need an complication T code. There are several different answers that could be correct. I was confused at to your answer regarding using the S code if the fracture was either trauma or pathologic.

Sorry for the confusion as when I mentioned the S code I was referring to traumatic Fx. If there was a pathologic Fx then the appropriate M8_ code should be first, followed by the periprosthetic M97 DX code. I believe the T codes are for mechanical complications such as broken/dislocated prosthesis, osteolysis, instability/loosening etc.... as I was just focusing on the Fx diagnosis here.

 

[mitchellde]

Thanks for clarifying. As for the T codes yes they are fo,r among other things, mechanical complications which could be the cause of a peri prosthetic fracture, in which case you use the T code and not the M97. So there are various answers depending upon the rest of the story.