Osteoporosis without current pathological fracture
Chapter 13:Diseases of the musculoskeletal system
ICD-10 M81 is a billable code used to indicate a diagnosis of osteoporosis without current pathological fracture.
Osteoporosis is a systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to increased bone fragility and susceptibility to fractures. The condition is often asymptomatic until a fracture occurs, which is why it is crucial to identify and manage osteoporosis before any pathological fractures develop. Osteoporosis without current pathological fracture indicates that the patient has low bone density but has not yet experienced a fracture due to this condition. Risk factors include age, gender (more common in postmenopausal women), family history, low body weight, and certain medical conditions or medications that affect bone metabolism. Diagnosis typically involves bone density testing (DEXA scans) to assess bone mineral density (BMD) and evaluate fracture risk. Management may include lifestyle modifications, dietary changes, and pharmacotherapy aimed at improving bone density and reducing fracture risk.
Detailed history of bone health, including family history, lifestyle factors, and results of bone density tests.
Patients presenting with low bone density, history of falls, or those on long-term corticosteroid therapy.
Endocrinologists must ensure that all relevant lab results and treatment plans are documented to support the diagnosis.
Documentation of any previous fractures, current bone health assessments, and treatment plans.
Patients with a history of fractures or those at high risk for fractures due to osteoporosis.
Orthopedic surgeons should document the rationale for surgical interventions in patients with osteoporosis.
Used for patients being evaluated for osteoporosis.
Results of the bone density test must be documented in the patient's record.
Endocrinologists should ensure that the test results are interpreted in the context of the patient's overall health.
M81 is used for patients with osteoporosis without current pathological fractures, while M80 is for those who have experienced a fracture due to osteoporosis.
