Fracture

Patient admitted to home health after fall with left femoral neck fracture. Patient had surgery and hardware was placed. Patient also has osteoporosis. My question is do I code fracture with 7th character, or do I code from M80-? Also, is there a code for presence of hardware? Thanks

Comments

  • The MD has to clearly state a relationship between osteoporosis and the fx you cannot assume. Code the fx with "D"
  • edited May 2017
    My coding book is the DH preliminary edition, so my page 1068 is the N section.
  • Stacey,
    The OP instructions are on page 1032 in your book under age-related OP with current path fx.
    The instructions Diane stated are ONLY IF the fall or trauma would not usually break a normal healthy bone.
    Here's the actual guideline:

    Section I.C.13.d.2)
    Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. 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.


    Nancy Wolverton RN,CCM
    QR Specialist, Central Office
    5800 West 10th St., Suite 300
    Little Rock, AR. 72205
    Ph# 501-280-4913
    Fax# 501-280-4385
    Nancy.Wolverton@arkansas.gov
  • Nancy is there a standard relation if the md does not specifically state this? Like (HTN/CKD) thanks!
  • That is a Lisa Selman-Holman question for sure.
    I do not assume. If the medical records state fracture, and an injury is documented and if it is not specifically stated as due to osteoporosis and is not documented as a pathological fracture, then I code it as trauma.

    Nancy Wolverton RN,CCM
    QR Specialist, Central Office
    5800 West 10th St., Suite 300
    Little Rock, AR. 72205
    Ph# 501-280-4913
    Fax# 501-280-4385
    Nancy.Wolverton@arkansas.gov
  • So in this instance wouldn’t it be coded with a "D"?
  • Yes. And the hardware is integral to the fracture repair. I would not code a hardware status code too.

    Nancy Wolverton RN,CCM
    QR Specialist, Central Office
    5800 West 10th St., Suite 300
    Little Rock, AR. 72205
    Ph# 501-280-4913
    Fax# 501-280-4385
    Nancy.Wolverton@arkansas.gov
  • Ahh perfect I wanted to be sure I had that right haha thanks!
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