Pathological Fractures

Definition: A bone fracture that occurs without adequate trauma, caused by an underlying disease.

Diagnostic Criteria

Identified in Radiology/Diagnostic Imaging such as X-Ray, CT, MRI, or bone scans.

There are various underlying causes for pathological fractures which can include, however are not limited to:

Coding Considerations:

All pathological fractures are classified to the following categories/subcategories according to the underlying cause:

ICD-10-CM Official Coding Guideline advice:

Section I.C.13.c.2 Osteoporosis with Current Pathological Fracture

Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathological 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.

Section 1.C.2.l.6 ‘Pathologic fracture due to neoplasm’

When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for neoplasm.

If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.

 Review pertinent Coding Clinics such as:

• AHA Coding Clinic, Fourth Quarter 2020, p. 32 ICD-10-CM New/Reviewed Codes: Osteoporosis Related Pathological Fractures
• AHA Coding Clinic, Second Quarter 2019, p. 35 “Kiva Kyphoplasty”
• AHA Coding Clinic, Second Quarter 2018, p. 12 “Osteoporosis and Fracture (Traumatic versus Pathologic)

CDI Practice Considerations

Review for underlying etiology of Fracture and query when necessary

• When sequenced as the PDx, pathological and traumatic fractures can map to different DRG’s, depending on location
• Pathological fractures that occur during an encounter, i.e., with a POA status of N, are excluded as Hospital Acquired Conditions (HAC).

Pathological fractures may occur with minor trauma

• If the Fracture is described as ‘spontaneous’ these are always pathological fractures.
• Providers often relate the term ‘pathological’ as correlating to malignancy, unaware the term also encompasses other common etiologies.
• One way to differentiate a potential pathological fracture from a traumatic fracture is to ask yourself if the trauma sustained would normally cause a fracture.
• So, for example, if a healthy 30 year fell from a sitting or standing position, would they likely break a bone?

Review the record closely for any significant trauma when the fracture is described as ‘compression.’

• Compression fractures can be pathological fractures or due to trauma
• Query the provider if documentation is unclear.

Be aware, only severe osteoporosis can be seen on x-rays

• Hence why DEXA scanning is used for diagnosis

Review medication administration reports (MAR) and home med lists closely for treatment

• Bisphosphonates are typically the first choice of treatment for osteoporosis, and some may be given in quarterly or annual IV infusion vs. weekly or monthly pills, so I/P MARs may not list them as active medications, making home medication list a must for review.
• Common medications to treat osteoporosis include:
  • Fosamax/Fosamax Plus D
  • Actonel/Actonel with Calcium/Atelvia
  • Boniva
  • Reclast
  • Prolia (typically given to those who can’t tolerate bisphosphonates related to reduced kidney function)
  • Vitamin D

Stress fractures are different from pathological fractures in that stress fractures are due to repetitive force applied before the bone and it’s supporting tissues have had enough time to absorb such forces.

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