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ICD-10 Guide
ICD-10 CodesM84.61

M84.61

Billable

Pathological fracture in other disease, shoulder

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

Code Description

ICD-10 M84.61 is a billable code used to indicate a diagnosis of pathological fracture in other disease, shoulder.

Key Diagnostic Point:

A pathological fracture in the shoulder occurs when the bone breaks due to underlying disease processes rather than trauma. This condition is often associated with bone density disorders such as osteoporosis, osteomalacia, or metastatic bone disease. In patients with osteoporosis, the structural integrity of the bone is compromised, leading to an increased risk of fractures even with minimal or no trauma. The shoulder, comprising the humerus, scapula, and clavicle, can be particularly vulnerable in individuals with weakened bone density. The fracture may present with pain, swelling, and limited range of motion, and is often diagnosed through imaging studies such as X-rays or MRIs. Treatment typically involves pain management, physical therapy, and in some cases, surgical intervention to stabilize the fracture. Understanding the underlying disease process is crucial for effective management and prevention of future fractures.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of underlying diseases affecting bone density.
  • Differentiation from traumatic fractures.
  • Need for comprehensive documentation of the underlying condition.
  • Potential for multiple comorbidities affecting coding.

Audit Risk Factors

  • Inadequate documentation of the underlying disease.
  • Failure to specify the type of fracture.
  • Misclassification of the fracture as traumatic.
  • Lack of supporting imaging reports.

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed notes on fracture type, location, and underlying conditions.

Common Clinical Scenarios

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

Billing Considerations

Ensure that all imaging and treatment plans are documented to support the diagnosis.

Endocrinology

Documentation Requirements

Comprehensive evaluation of bone density and metabolic disorders.

Common Clinical Scenarios

Patients with osteoporosis or metabolic bone diseases experiencing fractures.

Billing Considerations

Documenting the patient's bone density status and treatment history is crucial.

Coding Guidelines

Inclusion Criteria

Use M84.61 When
  • According to ICD
  • 10 guidelines, M84
  • 61 should be used when a fracture occurs due to an underlying disease process
  • Coders must ensure that the underlying condition is well
  • documented and that the fracture is not due to trauma
  • It is essential to follow the official coding guidelines for specificity and accuracy

Exclusion Criteria

Do NOT use M84.61 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 for pain management in patients with shoulder fractures.

Documentation Requirements

Document the indication for the procedure and the patient's response.

Specialty Considerations

Orthopedic specialists often perform this procedure for symptomatic relief.

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 these cases. M84.61 provides a clear distinction between fractures due to underlying diseases and those resulting from trauma, enhancing data accuracy and patient care.

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 these cases. M84.61 provides a clear distinction between fractures due to underlying diseases and those resulting from trauma, enhancing data accuracy and patient care.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of pathological fractures, improving the ability to capture the complexity of these cases. M84.61 provides a clear distinction between fractures due to underlying diseases and those resulting from trauma, enhancing data accuracy and patient care.

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 underlying disease processes that weaken the bone, while a traumatic fracture results from an external force or injury.