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v1.0.0
ICD-10 Guide
ICD-10 CodesM84.461

M84.461

Billable

Pathological fracture, right tibia

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

Code Description

ICD-10 M84.461 is a billable code used to indicate a diagnosis of pathological fracture, right tibia.

Key Diagnostic Point:

A pathological fracture of the right tibia occurs when the bone breaks due to an underlying disease process rather than from a traumatic injury. This type of fracture is often associated with conditions that weaken bone density, such as osteoporosis, osteogenesis imperfecta, or metastatic cancer. In patients with osteoporosis, the bone's mineral density is significantly reduced, making it more susceptible to fractures even with minimal or no trauma. The tibia, being a weight-bearing bone, is particularly vulnerable in these cases. Diagnosis typically involves imaging studies such as X-rays or CT scans to confirm the fracture and assess the extent of the underlying bone pathology. Treatment may include pain management, stabilization of the fracture, and addressing the underlying condition to improve bone health. Understanding the patient's history, including risk factors for bone density disorders, is crucial for accurate diagnosis and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of underlying bone density disorders.
  • Differentiation from traumatic fractures.
  • Need for comprehensive patient history.
  • Potential for multiple co-existing conditions affecting coding.

Audit Risk Factors

  • Inadequate documentation of underlying conditions.
  • Failure to specify the type of fracture.
  • Misclassification as a traumatic fracture.
  • Lack of imaging reports to support diagnosis.

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed imaging reports, patient history, and treatment plans.

Common Clinical Scenarios

Patients presenting with fractures after minimal trauma, history of osteoporosis.

Billing Considerations

Ensure documentation reflects the nature of the fracture and any underlying conditions.

Endocrinology

Documentation Requirements

Bone density test results, history of metabolic bone disease.

Common Clinical Scenarios

Patients with osteoporosis or other metabolic bone disorders experiencing fractures.

Billing Considerations

Documenting the relationship between metabolic disorders and fracture risk.

Coding Guidelines

Inclusion Criteria

Use M84.461 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate documentation of the fracture type and any underlying conditions
  • Include any relevant imaging studies and patient history to support the diagnosis

Exclusion Criteria

Do NOT use M84.461 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 joint aspiration is needed due to fracture-related complications.

Documentation Requirements

Document the reason for aspiration and findings.

Specialty Considerations

Orthopedic specialists may frequently perform this procedure in conjunction with fracture management.

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 track and manage conditions related to bone health and density disorders.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of pathological fractures, improving the ability to track and manage conditions related to bone health and density disorders.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of pathological fractures, improving the ability to track and manage conditions related to bone health and density disorders.

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, while a traumatic fracture results from an external force or injury.