Wiki Fracture/Osteoporosis

[warrenfamily103@gmail.com]

Good morning! I am trying to get some clarification on coding for an acute lumbar compression fracture. The documentation states that the patient has an L3 compression fracture that occurred on 9/4/21. The pain is almost resolved. It didn't say how it happened for me to determine whether it would be traumatic or non traumatic, so I reviewed the Ortho notes from that time period; it appears the patient hurt herself while lifting a dog over the couch. I chose the ICD-10 code of M48.56XD for this since this is not the initial encounter and she seems to be healing. The doctor also diagnosed the patient with Fibromyalgia and Osteoporosis. This is the first time I am seeing the Osteoporosis diagnosed. Would this code as Osteoporosis with current Pathological fracture or age related? The patient is 75 years old. Also, would the provider need to state age related? I appreciate any feedback.

 

[eagendj]

You cannot take a diagnosis from an older note. You should query the provider to find out how the fracture happened. You don't have enough information to determine this is not the initial encounter. Age related does not need to be stated by the provider to code the osteoporosis. It could be a compression fracture due to osteoporosis but you do not have enough information to code that until you query the provider.