Q&A: Clarifying the etiology of a fragility fracture

Q: How should a coder handle the documentation and coding of a fragility fracture when the underlying cause, such as osteoporosis, has not been clearly established?

A: Providers often use the term fragility fracture in their documentation. For example, suppose a provider documents a fragility fracture of the tibia and fibula resulting from a ground-level fall but does not mention osteoporosis. There are also no documented clinical indicators supporting osteoporosis. How should this be coded? Does osteoporosis need to be documented in order to assign a code from the M80.- category? Should the coder query for osteoporosis?

The coder would not query specifically for osteoporosis unless there are clinical indicators supporting that diagnosis. For example, is the patient receiving treatment for osteoporosis? Is there anything else in the medical record suggesting that the patient has osteoporosis? If there are supporting clinical indicators, then a query for osteoporosis may be appropriate.

Additionally, when you look up “Fragility” under “Fracture, traumatic” in the ICD-10-CM Alphabetical Index, you are directed to see “Fracture, pathological, due to osteoporosis.” Therefore, when a fragility fracture is documented without evidence of osteoporosis, the coder needs additional information about the underlying cause of the fracture.

Rather than asking specifically whether the patient has osteoporosis, the query should clarify the etiology of the fragility fracture. The fracture could potentially be related to another underlying condition or factor, such as cancer, immunosuppressive medication use, or an autoimmune disorder. The goal is to determine what condition, if any, caused the fragility fracture. If the provider does not identify or confirm a specific etiology after clarification, the fracture would be reported from category M84.4- (pathological fracture, not elsewhere classified). In that situation, greater specificity cannot be assigned because the underlying cause has not been established.

So, in this example, a query would be appropriate—but not necessarily a query specifically for osteoporosis. Instead, the query should ask the provider to clarify the etiology of the documented fragility fracture.

Editor’s note: This question and answer were originally published in JustCoding, which adapted them from a discussion with Lynette Byerly, BSN, RN, CCDS, CCS, CDI education specialist at ACDIS/HCPro, on The ACDIS Podcast.