Patients with osteoporosis and a fracture
Is it necessary to query for all patients with osteoporosis and a fracture can we just make the link and code pathological fractures?
This is from the Official Coding Guidelines: I.C.13.d.2: “A code from category M80 [Osteoporosis with current pathological fracture], 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.”
CDI and coding specialists should usually be able to make this determination without a query and encouraged to do so pursuant to the above OCG section; if uncertain, query the provider but only if impactful.
Most patients over age 60 years who sustain fractures after minor trauma (like falling from a standing position) have osteoporosis.
X-ray cannot detect osteoporosis until it has become severe, and radiologists often use the term "osteopenia" ("poverity" of bone) to describe the x-ray appearance of severe osteoporosis. Clinical osteopenia is a precursor of osteoporosis. Neither clinical osteopenia nor mild to moderate osteoporosis can be seen on x-ray which is why DEXA scanning is used for diagnosis. Only severe osteoporosis can be seen on x-ray.
Terms classified in ICD-10 as pathologic fractures include osteoporotic, fragility, neoplastic, non-traumatic, insufficiency, spontaneous, chronic
However, there is also this coding clinic: Osteoporosis and fracture (traumatic versus pathologic)
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2018 Page: 12 Effective with discharges: June 6, 2018
Question:
A 75-year-old patient with osteoporosis sustained a ground level fall, resulting in a right displaced mid-shaft femoral fracture. In this case, would it be appropriate to assign code M80.051A, Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture, for the displaced mid-shaft femoral fracture?
Answer:
Query the provider as to whether the clinical history is consistent with an osteoporotic pathologic fracture. If the provider confirms osteoporotic pathologic fracture, assign code M80.051A, Age related osteoporosis with current pathological fracture, right femur, initial encounter for fracture.
Assign code S72.301A, Unspecified fracture of shaft of right femur, initial encounter for closed fracture, if the provider documents the fracture occurred secondary to trauma from the fall.
The Official Guidelines for Coding and Reporting, Section I. C. 13. D. 2. state "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."