Pain Management Coding Alert

Reader Question:

Remember Fracture History on Osteoporosis Dx

Question: The PM specialist treated a patient with osteoporosis. The patient doesn't have a current pathological fracture, but notes indicate that she did have an osteoporosis fracture of her right foot three years ago that has since healed. What ICD-10 codes should I choose for this patient's condition?

Florida Subscriber

Answer: You'll need one diagnosis code for the patient's current osteoporosis and another for her fracture history.

First Dx: For a primary diagnosis, you'll append one of the following ICD-10 codes for the patient's current osteoporosis:

  • M81.0 - Age-related osteoporosis without current pathological fracture
  • M81.6 - Localized osteoporosis (Lequesne)
  • M81.8 - Other osteoporosis without current pathological fracture.

Second Dx: You'll also need Z87.310 (Personal history of (healed) osteoporosis fracture) as a secondary diagnosis. As the instructions below M81.0 instruct coders, you should use an additional code to identify "personal history of (healed) osteoporosis fracture, if applicable."