A 75-year-old patient with osteoporosis sustained a ground level fall, resulting in a right displaced mid-shaft femoral fracture. In this case, would it be appropriate to assign code M80.051A, Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture, for the displaced mid-shaft femoral fracture?
Query the provider as to whether the clinical history is consistent with an osteoporotic pathologic fracture. If the provider confirms osteoporotic pathologic fracture, assign code M80.051A, Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture.
Assign code S72.301A, Unspecified fracture of shaft of right femur, initial encounter for closed fracture, if the provider documents the fracture occurred secondary to trauma from the fall.The Official Guidelines for Coding and Reporting, Section I. C. 13. D. 2. state “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.”