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ICD-10 Guide
ICD-10 CodesM84.411

M84.411

Billable

Pathological fracture, right shoulder

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/17/2025

Code Description

ICD-10 M84.411 is a billable code used to indicate a diagnosis of pathological fracture, right shoulder.

Key Diagnostic Point:

A pathological fracture of the right shoulder occurs when a bone in the shoulder region breaks due to an underlying disease process rather than from an acute injury. This type of fracture is often associated with conditions such as osteoporosis, which leads to decreased bone density and increased fragility. Osteoporosis is characterized by a reduction in bone mass and deterioration of bone tissue, making bones more susceptible to fractures even with minimal trauma. In the case of the right shoulder, the fracture may involve the humerus or scapula, and it can result from various factors, including age-related bone loss, hormonal changes, or chronic diseases that affect bone metabolism. Patients with a pathological fracture may present with pain, swelling, and limited range of motion in the shoulder. Diagnosis typically involves imaging studies such as X-rays or MRI to confirm the fracture and assess the extent of bone loss. Management may include pain control, physical therapy, and treatment of the underlying condition to prevent future fractures.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between traumatic and pathological fractures
  • Understanding the underlying conditions contributing to bone fragility
  • Accurate documentation of the fracture site and type
  • Knowledge of associated conditions like osteoporosis

Audit Risk Factors

  • Inadequate documentation of the underlying condition
  • Failure to specify the exact location of the fracture
  • Misclassification of the fracture type (pathological vs. traumatic)
  • Lack of supporting imaging documentation

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed imaging reports, clinical notes on fracture assessment, and treatment plans.

Common Clinical Scenarios

Patients presenting with shoulder pain and a history of osteoporosis or previous fractures.

Billing Considerations

Ensure that the underlying bone density disorder is well-documented to support the diagnosis of a pathological fracture.

Endocrinology

Documentation Requirements

Documentation of bone density tests, treatment plans for osteoporosis, and follow-up care.

Common Clinical Scenarios

Patients with osteoporosis who experience fractures or are at high risk for fractures.

Billing Considerations

Documenting the patient's bone health status and any medications affecting bone metabolism is crucial.

Coding Guidelines

Inclusion Criteria

Use M84.411 When
  • According to ICD
  • 10 coding guidelines, M84
  • 411 should be used when a fracture is confirmed to be pathological due to an underlying condition
  • Coders must ensure that the documentation supports the diagnosis and includes details about the patient's bone health

Exclusion Criteria

Do NOT use M84.411 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

20610CPT Code

Arthrocentesis, aspiration and/or injection into a major joint or bursa

Clinical Scenario

Used when a patient with a pathological fracture requires joint aspiration for diagnostic purposes.

Documentation Requirements

Document the reason for the procedure and the findings from the aspiration.

Specialty Considerations

Orthopedic specialists should ensure that the procedure is justified based on the patient's condition.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of pathological fractures, improving the ability to capture the complexity of bone health issues. M84.411 provides a clear distinction between traumatic and pathological fractures, which is essential for accurate treatment planning and reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of pathological fractures, improving the ability to capture the complexity of bone health issues. M84.411 provides a clear distinction between traumatic and pathological fractures, which is essential for accurate treatment planning and reimbursement.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the difference between a pathological fracture and a traumatic fracture?

A pathological fracture occurs due to an underlying disease that weakens the bone, such as osteoporosis, while a traumatic fracture results from an external force or injury.