Osteoporosis ICD-10-CM Coding
For osteoporosis ICD-10 diagnosis coding, you have to know what type of osteoporosis the patient has been diagnosed with.
Osteoporosis is the most common metabolic bone disease, and is characterized by diffuse reduction in bone density due to a decrease in the bone mass. Causes may include senility (old age), inadequate intake of calcium and vitamin D, and protein deficiency. Osteoporosis also may be related to endocrinal conditions, such as Cushing syndrome, hyperthyroid state, thyrotoxicosis, and diabetes mellitus. Finally, osteoporosis may be drug induced, for instance as a result of long-term steroid therapy. Risk factors for osteoporosis are aging, hypocalcemia, vitamin D deficiency, and osteomalacia.
Osteoporosis is an asymptomatic unless complications (e.g., fracture) occur. Loss of bone mass leads to loss of bone strength, such that even a trivial trauma may be severe enough to cause a fracture.
Treatment for osteoporosis aims to alleviate pain and prevent fractures, and may include orthopedic treatment (e.g., exercises, bracing) and medical treatment (e.g., high protein diet, calcium supplementation, vitamin D replacement, alendronate, and calcitonin.
Selecting a Diagnosis Code
Osteoporosis ICD-10 coding depends on the type of osteoporosis, of which there are three:
1. Age related osteoporosis with current pathological fracture, which includes:
• Involutional osteoporosis
• Postmenopausal osteoporosis
• Senile osteoporosis
• Osteoporosis NOS
2. Other osteoporosis with current pathological fracture, which includes:
• Drug induced osteoporosis
• Idiopathic osteoporosis
• Osteoporosis of disuse
• Post-oophorectomy osteoporosis
• Postsurgical malabsorption osteoporosis
• Posttraumatic osteoporosis
The M80 series of codes is appropriate for either age-related osteoporosis or other osteoporosis, with current pathological fracture. Codes are selected according to the anatomical site of the fracture, not the location of the osteoporosis.
3. Osteoporosis without current pathological fracture
If the patient does not have current pathological fracture, you should select a code from the M81 series (even if the patient had pathological fracture in the past).
A sixth digit indicates laterality. For example:
M80.811 Other osteoporosis with current pathological fracture, right shoulder
M80.812 Other osteoporosis with current pathological fracture, left shoulder
M80.819 Other osteoporosis with current pathological fracture, unspecified shoulder
Additionally, a seventh digit indicates the episode of care, as follows:
• A initial encounter for fracture
• B Initial encounter for fracture routine healing
• G subsequent encounter for fracture delayed healing
• K subsequent encounter for fracture with nonunion
• P subsequent encounter for fracture for malunion
• S sequela
Best Practice Documentation
When documenting osteoporosis fracture, the provider should define the episode of care (e.g., initial, routine, or delayed healing). The provider must also specify location and laterality (e.g., left or right). If the patient has pathological fracture, the provider needs to indicate the precise classification (e.g. Senile osteoporosis, posttraumatic osteoporosis).
Clinical Example: Postmenopausal osteoporosis with current pathological fracture, left humerus, initial encounter for fracture
Osteoporosis ICD-10 Coding: M80.022A