Osteoporosis ICD-10-CM codes

Osteoporosis without a current fracture is category M81, and age-related (postmenopausal, senile) osteoporosis is M81.0, which is by far the most common code. M81.8 covers other osteoporosis such as drug-induced or disuse osteoporosis. The official guidelines state that the site is not part of these codes because osteoporosis is a systemic disease; M81 codes never have laterality. A patient with osteoporosis and a previously healed fragility fracture is M81.0 plus Z87.310 (personal history of healed osteoporosis fracture).

When a patient has a current fragility fracture, use category M80 instead of M81 and do not add a traumatic fracture code from chapter 19. M80.0- is age-related osteoporosis with fracture and M80.8- is other osteoporosis with fracture. The 5th character is the fracture site (0 unspecified, 1 shoulder, 2 humerus, 3 forearm, 4 hand, 5 femur, 6 lower leg, 7 ankle and foot, 8 vertebra, A other site), the 6th is laterality, and the 7th character reports the encounter: A initial, D subsequent with routine healing, G delayed healing, K nonunion, P malunion, S sequela. A right hip fracture from osteoporosis at the first visit is M80.051A; a compression fracture of a vertebra is M80.08XA.

Per guideline I.C.13.d, a fracture in an osteoporotic patient that follows a minor fall or trauma that would not break normal bone is coded to M80, provided the provider documents the fracture as osteoporotic or pathological. M80 is a combination code, so M81 is not reported with it. Add Z79.83 for long-term bisphosphonate use and Z91.81 for a documented history of falling. Osteopenia is M85.8-, not osteoporosis.