ED Coding and Reimbursement Alert

Hint: Osteoporotic fractures might not be coded from the fracture section.

It's likely that your ED sees patients with bone fractures every day, but coding these services can be a challenge, especially when underlying conditions are also involved. Knowing a few quick tips can help you iron out the appropriate diagnosis codes to report.

Pathologic Fx, Neoplasms? Rely on Treatment Focus

Suppose the ED physician sees a patient for a suspected spine fracture, orders diagnostic tests and finds that the radiology report reveals pathologic spinal fractures due to a neoplasm.

"A pathologic fracture simply means that the fracture is caused by some invasive process," says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. "Most pathologic fractures of the spine are due to malignancies, but benign neoplasms can result in pathologic fractures as well - in addition to infections of the bone, such as osteomyelitis," Rosenberg explains.

While coders generally want to code the underlying disease as the primary diagnosis, you should abide by the ICD-10-CM guidelines' instructions to code the condition being treated as the primary diagnosis:

• "When an encounter is for a pathological fracture due to a neoplasm, and 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."

Since ED physicians would almost always be treating the fracture and not the neoplasm, the M84.5 code would typically be the primary diagnosis. If the neoplasm is known, you can code that as a secondary diagnosis.

Code as Osteoporosis, not Fx, for Osteoporotic-Induced Fxs

ICD-10 also includes a set of guidelines that could understandably be a source of confusion for some coders. Consider an example of a patient diagnosed with an L1 osteoporotic fracture. Now, consider these ICD-10-CM guidelines on coding for osteoporotic fractures:

"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."

The guidelines are fairly straightforward, so the correct diagnosis code should be, too. Based on these rules, coders should apply diagnosis code M80.08XA (Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture).