Q&A: Coding a periprosthetic fracture due to injury

Q: What ICD-10-CM code should we report for a periprosthetic fracture due to an injury? Do you use the S codes for a traumatic fracture with a secondary code for replacement, or do you select a code from the M97 (Periprosthetic fracture around internal prosthetic joint) category?

A: For a traumatic periprosthetic fracture, the American Hospital Association advises you to report both an S code and a code from category M97, according to the October 2016 AHA Coding Clinic. Similarly, if you have a periprosthetic fracture that is pathological in origin, you’d report a code from category M84 as well as the appropriate M97 code.

When a traumatic or pathologic fracture occurs around a prosthetic joint, you should sequence the traumatic or pathological fracture code first, followed by the appropriate code from category M97 for a periprosthetic fracture, Coding Clinic instructs.

Note that the guidance to report two codes for periprosthetic fractures does not appear in either the ICD-10-CM tabular section or the ICD-10-CM Official Guidelines for Coding and Reporting. Coding Clinic also is considered an authoritative coding resource for ICD-10.

The American Academy of Orthopaedic Surgeons Coding Committee requested that the periprosthetic fracture ICD-10-CM codes be moved to the M97 range from the T84.04 sub-category, because these are not caused by a complication of the prosthesis, but by a fracture that occurred around the prosthesis.

For example, a patient with a hip replacement trips and falls and has a traumatic periprosthetic fracture of the lower end of the right femur. You would report ICD-10-CM codes S72.401A (Unspecified fracture of lower end of right femur, initial encounter for closed fracture) and M97.01XA (Periprosthetic fracture around internal prosthetic right hip joint, initial encounter).

In the same way, for a patient with a prosthetic hip who sustains a pelvic fracture after stepping off a curb, you’d list ICD-10-CM code M84.454A (Pathological fracture of pelvis, initial encounter), then M97.01XA.

By contrast, the complication codes in the T84.01- subcategory are to be reported “for breakage (fracture) of prosthetic joints” (e.g., when there is a problem with the prosthesis itself), Coding Clinic instructs.

If a fracture occurs intraoperatively during the implant of a prosthetic joint, you would report a code from category M96.6 (Fracture of bone following insertion of orthopedic implant, joint prosthesis or bone plate), the ICD-10-CM manual instructs.

Editor’s note: This information originally appeared in JustCoding. This information was excerpted from 2024 Orthopedic Coding & Documentation Trainer. This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.