Coding Tip: Periprosthetic Fracture Reporting and Sequencing

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

There are approximately 6.3 million fractures reported each year in the united states and most are due to trauma. Disease can also cause a bone to fracture and this fracture type is known as a pathological fracture. A pathological fracture is usually spontaneous but may also result from a minor trauma that fractures from the diseased bone. Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.

What is a Periprosthetic Fracture?

Periprosthetic fractures are fractures that occur around a prosthesis. They are not complications of the prosthesis but are caused by either trauma or disease (pathological). These fractures are not coded as a complication since they don’t actually involve the implant. ICD-10-CM has specific codes for periprosthetic fractures.

How is a Periprosthetic Fracture Coded and Sequenced?

Periprosthetic fractures are coded within Chapter 13 of ICD-10-CM in category M97. A minimum of two codes are required when reporting the periprosthetic fractures. One code for the periprosthetic fracture and another for the type of fracture, such as traumatic vs. pathological with the underlying condition. If the reason for admission/encounter is for the fracture then the fracture would be sequenced first and then the periprosthetic fracture code as a secondary diagnosis code.

Examples:

• Patient is admitted for new periprosthetic fracture of the lower end of the left femur after falling down 4 steps. This fracture is documented to not involve the actual joint prosthesis. In this case, report ICD-10-CM codes S72.402A (Unspecified fracture of lower end of left femur, initial encounter for closed fracture) as the principal/first listed diagnosis followed by M97.02XA (Periprosthetic fracture around internal prosthetic left hip joint, initial encounter) as a secondary diagnosis. (Also assign external cause codes)
• Patient is status post left shoulder replacement and presents for periprosthetic fracture of the humerus after rolling over in the bed. The patient was worked up and it was found that the fracture was due to underlying osteoporosis. There was no fracture of the actual joint prosthesis. In this case, report ICD-10 CM codes M84.422A (Pathological fracture, left humerus, initial encounter for fracture) as the principal/first listed diagnosis followed by M97.32XA (Periprosthetic fracture around internal prosthetic left shoulder joint, initial encounter) as a secondary diagnosis. (Also assign osteoporosis and external cause codes)

If the actual joint prosthesis is broken then the fracture would be coded as a complication of internal joint prosthesis and sequenced as the principal/first listed diagnosis code.

References
ncbi.nlm.nih.gov/pmc/articles/PMC5726208
https://www.niams.nih.gov/health-topics/hip-replacement-surgery
emedicine.medscape.com/article/1269334
orthoinfo.aaos.org/en/disease-conditions/fracture-after-total-hip-replacement/
I-10 Coding Handbook
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2016 Page: 42
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2018 Page: 21

Happy Coding!

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.