Pathological fracture coding tips

When you start coding pathological fracture, it is essential to know the causative reason for the fracture to assign the appropriate codes. A fracture can be either a traumatic or pathologic (non-traumatic) and the documentation must specify the reason for the fracture to select the appropriate code sets. Insufficient documentation always leads to improper fracture coding. Therefore coders must query provider when they miss any information regarding fracture occurrence and the site.

Pathologic fracture:

A pathologic fracture is a broken bone that is caused by a disease, rather than an injury. These fractures occur during an activity that normally would not cause a fracture, but due to the disease process, it weakens your bones that make them more likely to break even under normal circumstances. Most common diseases responsible for causing pathologic fracture would include the following:

  • Malignancy
  • Osteoporosis
  • Osteomyelitis
  • Osteomalacia
  • Other conditions like osteogenesis imperfecta, hyperparathyroidism, noncancerous tumors and cysts.

Traumatic fracture:

A traumatic fracture is caused by some type of accident, fall, or other kind of force. For example, a traumatic fracture can occur during a motor vehicle accident or when a person is struck with a heavy object.

Pathological fracture code categories:

The code categories for pathologic fracture are classified on the type of disease process that is responsible for the fracture to occur.

  • M84.4 Pathological fracture, not elsewhere classified
  • M84.5 Pathological fracture in neoplastic disease
  • M84.6 Pathological fracture in other diseases
  • M80 Osteoporosis with current pathological fracture
  • M81 Osteoporosis without pathological fracture

Let’s see each code category separately as below for better understanding:

Pathological fracture in neoplastic disease: M84.5

Under code category M84.5, you can see an instruction as “code also underlying neoplasm”.This instruction alerts the coder that when an encounter is for a pathological fracture due to a neoplasm, an additional code specifying the neoplasm should also be coded in the encounter. However the sequencing is based on the focus of treatment provided for the condition.

  • If the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for the neoplasm.
  • If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture

Figure representing the sequencing of pathological fracture in neoplastic disease:

Pathological fracture in other diseases: M84.6

Under code category M84.6, you can see an instruction as “code also underlying condition”.This instruction alerts the coder that when an encounter is for a pathological fracture due to other disease process, an additional code specifying the condition should also be coded in the encounter. Other specified disease may include Paget’s disease, disuse atrophy, hyperparathyroidism, and nutritional or congenital disorders.

Osteoporosis is a systemic condition indicating that all bones of the musculoskeletal system are affected. There is a separate section for Osteoporosis with a current pathologic fracture that fall under category M80. You need to identify the following factors to assign the appropriate codes for osteoporosis associated with pathologic fracture.

1. Whether the osteoporosis occurs with or without current pathologic fracture and history of pathologic fracture. For osteoporosis with current pathological fracture, select category M80. For osteoporosis without pathological fracture, select category M81.

2. Determine the specific bone fractured and its laterality as appropriate in category M80. Category M81 does not have the location as a component in its code sets.

3. Determine whether the osteoporosis is age-related or due to some other specific cause.

4. Indicate the episode of care by adding appropriate seventh character to the codes.

Osteoporosis with current pathological fracture: M80

Category M80 is used for patients who have a current pathologic fracture at the time of the encounter. The codes under M80 identify the site of the fracture and not the osteoporosis site. It is further subdivided into:

Age-related osteoporosis with current pathological fracture: M80.0

  • Involutional osteoporosis with current pathological fracture
  • Osteoporosis NOS with current pathological fracture
  • Postmenopausal osteoporosis with current pathological fracture.
  • Senile osteoporosis with current pathological fracture

Other osteoporosis with current pathological fracture: M80.8

  • Drug-induced osteoporosis with current pathological fracture
  • Idiopathic osteoporosis with current pathological fracture
  • Osteoporosis of disuse with current pathological fracture
  • Postoophorectomy osteoporosis with current pathological fracture
  • Postsurgical malabsorption osteoporosis with current pathological fracture
  • Post-traumatic osteoporosis with current pathological fracture

Osteoporosis without pathological fracture: M81

Category M81 is used for patients who have osteoporosis that do not currently have a pathologic fracture (due to the osteoporosis) even if they had a fracture in the past. There are only three codes available in this category as the location is not considered to be a component of these codes.

M81.0 – Age-related osteoporosis without current pathological fracture

M81.6 – Localized osteoporosis

M81.8 – Other osteoporosis without current pathological fracture.

For patients with a history of osteoporosis fracture, status code Z87.310, personal history of (healed) osteoporosis fracture, should be coded following the code M81.

Episode of care:

When coding pathologic fractures, it is important to denote the episode of care by adding the appropriate seventh character to each code from the relevant subcategories. Missing the seventh character will result in an “incomplete code” thereby causing denials. For codes that are less than six characters, a placeholder X must be used to fill in for the empty characters. The seventh character in the code section is as follows:

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 non-union

P: Subsequent encounter for fracture with malunion

S: Sequela

Happy learning! Happy coding!

Resources:

https://providers.amerigroup.com/Documents/ALL_CARE_CB_FracturesBrochure.pdf

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