Osteoporosis ICD-10 CM Coding Guide for Coders

Basics of Osteoporosis ICD-10 CM Coding

Osteoporosis is a systemic condition that affects all bones of the musculoskeletal system and leads to an increased risk of pathological fractures. In osteoporosis, the bones are thinner and weaker than normal. Osteoporosis is classified to categories M80 and M81 depending on whether a current pathological fracture is present or not. Because osteoporosis is a systemic condition, site is not a component of the codes under category M81, Osteoporosis without current pathological fracture. The codes under category M80, Osteoporosis with current pathological fracture, identify the Osteoporosis and the site of the pathological fracture. The billable ICD 10 code for osteoporosis, unspecifed is M81.0, it is mainly used in coding DEXA scan or bone density scan procedure codes. Osteopenia and Osteoporosis are the main diagnosis used for coding DEXA scan exams.

Description of Osteoporosis ICD-10 CM codes.

M81 Osteoporosis without current pathological fracture
Use additional code to identify:
major osseous defect, if applicable (M89.7-)
personal history of (healed) osteoporosis fracture, if applicable (Z87.310)
Excludes1: osteoporosis with current pathological fracture (M80.-)
Sudeck’s atrophy (M89.0)

M81.0 Age-related osteoporosis without current pathological fracture
Involutional osteoporosis without current pathological fracture
Osteoporosis NOS
Postmenopausal osteoporosis without current pathological fracture
Senile osteoporosis without current pathological fracture

M81.6 Localized osteoporosis [Lequesne]
Excludes1: Sudeck’s atrophy (M89.0)

M81.8 Other osteoporosis without current pathological fracture
Drug-induced osteoporosis without current pathological fracture
Idiopathic osteoporosis without current pathological fracture
Osteoporosis of disuse without current pathological fracture
Postoophorectomy osteoporosis without current pathological fracture
Postsurgical malabsorption osteoporosis without current pathological fracture
Post-traumatic osteoporosis without current pathological fracture 

Applicable stages (or types)

There are four types of osteoporosis:

Idiopathic juvenile osteoporosis occurs in adolescence. Children diagnosed with this condition show little bone growth and have an increased likelihood of fractures.

Osteogenesis imperfecta is a rare form of osteoporosis that people are born with. It leads to breakage of bone without any apparent reason.

Primary osteoporosis is the most common type of osteoporosis that is observed more frequently in women than men, particularly postmenopausal women. This type of osteoporosis typically occurs between 45 and 55 years of age, when bones become thin and fragile.

Secondary osteoporosis presents with the same symptoms as primary osteoporosis, but is the result of medical conditions such as leukemia and hyperthyroidism.

Symptoms

Common symptoms of osteoporosis include:

• Backache
• Fractures of the spine, wrist, or hip
• Gradual loss of height
• Stooped posture

Treatment

Treatment for osteoporosis includes:

• Anabolic medications, or drugs that increase the rate of bone formation.
• Antiresorptive medications, or drugs that slow the rate of bone loss.
• Calcium and vitamin D supplements

Documentation and Coding

ICD-10-CM

Code M81.0 (age-related osteoporosis without current pathological fracture) should be used to report age-related osteoporosis, also known as senile, post-menopausal, or involutional osteoporosis. This code is reported whenever unspecified osteoporosis is documented.

For patients with a history of osteoporosis fractures, status code Z87.310 (personal history of healed osteoporosis fracture) should follow code M81.0.

Read also: Osteoarthritis ICD 10 coding guide for coders

Related Synonyms Include:

Osteoporosis
Osteoporosis (significant thinning of bone)
Osteoporosis, postmenopausal
Age related osteoporosis
Osteoporosis, senile
Pathologic osteoporosis
Postmenopausal osteoporosis
Senile osteoporosis

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Basic ICD-10 INFORMATION

World Health Organization (WHO) authorized the publication of the International Classification of DiseasesExternal 10th Revision (ICD-10), which was implemented for mortality coding and classification from death certificates in the U.S. in 1999. The U.S. developed a Clinical Modification (ICD-10-CM) for medical diagnoses based on WHO’s ICD-10.  This medical classification list is generated by the World Health Organization (WHO), and is used to help healthcare providers identify and code health conditions.

ICD-10 is required for use by physicians and healthcare providers under the Health Insurance Portability & Accountability Act (HIPAA) and will replace all ICD-9 code sets. There are nearly 5 times as many diagnosis codes in ICD-10-CM than in ICD-9-CM.ICD-10 has alphanumeric categories instead of numeric ones.