Periprosthetic Fracture Coding and Sequencing

There are approximately 6.3 million fractures reported each year in the United States and most are due to trauma, but fractures can result from other causes. A spontaneous fracture of a diseased bone is called a pathological fracture. Repetitive stress in weight bearing bones, such as those in the lower leg and foot can cause stress fractures.

What is a Periprosthetic Fracture?

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

How is a Periprosthetic Fracture Coded and Sequenced?

In ICD-10-CM, periprosthetic fractures are reported with codes from category M97 Periprosthetic fracture around internal prosthetic joint. There is an instructional note under M97 that states "Code first, if known, the specific type and cause of fracture, such as traumatic or pathological."

At the direction of the “Code first” note a minimum of two codes are required when reporting periprosthetic fractures. One code is assigned from category M97 that identifies the fracture as periprosthetic and identifies the specific joint involved (ankle, knee, hip, shoulder, elbow, finger, spine, toe, wrist) including the laterality of the condition. A second code is assigned to report the specific type and cause of the fracture (traumatic vs. pathological). Based on the instructional note, the code for the type of fracture is sequenced first followed by the periprosthetic fracture code.

Examples:

• Patient is admitted for new periprosthetic fracture of the lower end of the left femur after falling down 4 steps. The fracture does 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 M97.12XA (Periprosthetic fracture around internal prosthetic left knee joint, initial encounter) as a secondary diagnosis. 
• Patient is status post left shoulder replacement and presents for periprosthetic fracture of the humerus after rolling over in 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 a code for osteoporosis)

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

References

• https://www.niams.nih.gov/health-topics/hip-replacement-surgery
  
• 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