Radiology Coding Alert

Question: A 65-year-old patient with a history of osteoporosis visited our urgent care clinic complaining of severe right heel pain. The patient stepped awkwardly off their porch two days prior. After a physical exam, the physician ordered X-rays of the patient’s heel. The radiologist captured lateral and anteroposterior (AP) views of the patient’s heel and reported their findings. Following a review of the radiology report, the physician diagnosed the patient with a stress fracture of the right calcaneus due to osteoporosis.

Will 73620 suffice to report the X-rays of the patient’s foot?

Oklahoma Subscriber

Answer: While 73620 (Radiologic examination, foot; 2 views) includes “foot” in the code descriptor, you’ll want to assign 73650 (Radiologic examination; calcaneus, minimum of 2 views) to report the X-rays. The radiologist captured two views — lateral and AP — of the patient’s heel to evaluate the body structure. The calcaneus is the large bone that makes up the heel and is one of the largest tarsal bones in the foot.

The physician diagnosed the patient with a stress fracture due to osteoporosis. Before reporting the diagnosis, you’ll want to review ICD-10-CM Official Guidelines, Section I.C.13.d.2, which covers osteoporosis with a current pathological fracture. The guideline instructs that category M80.- (Osteoporosis with current pathological fracture) is designated for patients who have a current pathological fracture at the time of the encounter. You should assign a code from the M80.- category “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.”

When you turn to the ICD-10-CM Alphabetic Index, you’ll start with Osteoporosis and follow the indentations to age-related > with current pathological fracture > tarsus M80.07 (Age-related osteoporosis with current pathological fracture, ankle and foot). When you verify the code in the tabular list, you’ll find three codes under M80.07- requiring 6th and 7th characters to complete the codes.

Since the diagnosis is for a fracture of the right heel bone, you’ll assign M80.071A (Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture) with the 7th character A denoting the type of encounter for care.