While not directly addressing this question, Coding Clinic 1993, fourth quarter gives us a coding paradigm. In summary, the physician documentation must state if the injury is in accordance with the degree of trauma in order to connect any bone pathology findings to the injury. If not, you code the injury first, and then the underlying disease, followed by an E-code for the cause.
Below is the coding clinic:
A pathologic fracture is defined as a break in a diseased bone due to weakening of the bone structure by pathologic processes (such as osteoporosis or bone tumors) without any identifiable trauma or following only minor trauma. Only the physician can make the determination that the fracture is out of proportion to the degree of trauma. X-ray indications of diseased bone may be used by the physician to arrive at a diagnosis of a pathologic fracture, but should not be used by coders to make this determination.
Fifth digits have been added to category 733.1, Pathologic fracture, to allow identification of the site of the fracture. Codes from 800-829 for traumatic fractures should never be used with a code from this category. External cause of injury codes (E-codes) may be used if the pathologic fracture follows minor trauma to identify the nature of this trauma. The new codes are as follows:
733.10 Pathologic fracture, unspecified site
733.11 Pathologic fracture of humerus
733.12 Pathologic fracture of distal radius and ulna Wrist NOS
733.13 Pathologic fracture of vertebrae Collapse of vertebra NOS
733.14 Pathologic fracture of neck of femur Hip NOS Femur NOS
733.15 Pathologic fracture of other specified part of femur
733.16 Pathologic fracture of tibia and fibula
733.19 Pathologic fracture of other specified site
After walking out of a nursing home and falling off the curb, an 89 year old woman, with a history of severe osteoporosis, is admitted to the hospital for a fractured left hip. X-rays show advanced osteoporosis, separation of the acetabulum, and crumbling fracture of head of the left femur. Should the fracture be coded as pathological or as the result of trauma?
This is a clinical question that must be directed to the patient's physician. Sometimes minor trauma can cause a fracture in an individual with severely diseased bone, and that is called a pathological fracture. Only the physician can determine whether or not the level of injury is in accordance with the degree of trauma suffered by the patient.
If the physician determines that the fracture is due to trauma then only a code(s) from 800-829, Fractures, would be assigned. A code from category 733.0, Osteoporosis, may also be assigned. The pathological fracture code would not be assigned.
If, however, the physician determines that the fracture is pathological and due to osteoporosis, then code 733.14, Pathological fracture of neck of femur, and a code from category 733.0, Osteoporosis, should both be assigned. Code E888, Other and unspecified fall, may also be assigned.
Â© Copyright 1984-2006, American Hospital Association("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.
Maria Shinn Bouck, CPC, CPMA, CHC
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