2025 ICD-10-CM code M81
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Musculoskeletal - Disorders of bone density and structure Chapter XIII: Diseases of the musculoskeletal system and connective tissue Feed
Osteoporosis without current pathological fracture.
Medical necessity for diagnosis and treatment of osteoporosis is established based on risk factors, symptoms, and BMD measurements indicating a significant risk of fracture.Treatment is deemed medically necessary to prevent fractures and improve bone health.
Diagnosis and management of osteoporosis involves obtaining a detailed patient history, performing a physical examination, ordering and interpreting bone density tests (DEXA scan), and potentially reviewing blood and urine lab results. Treatment may involve lifestyle modifications, supplementation, and prescription medications.
- Chapter XIII: Diseases of the musculoskeletal system and connective tissue
- M80-M94 Osteopathies and chondropathies; M80-M85 Disorders of bone density and structure
In simple words: Osteoporosis is a condition where bones become weak and brittle, making them more likely to break.It usually develops slowly without causing pain until a bone breaks. Doctors diagnose osteoporosis through tests that measure bone density.Treatment may include changes to diet and exercise, supplements, and medications.
Osteoporosis without a current pathological fracture is characterized by a decrease in bone mass and density, leading to increased bone fragility and susceptibility to fractures.It typically develops gradually, often without noticeable symptoms until a fracture occurs. Diagnosis involves a thorough patient history, physical examination, and bone mineral density testing (e.g., DEXA scan).Treatment may include lifestyle modifications (diet, exercise, calcium and vitamin D supplementation), and medication (bisphosphonates, hormone therapy).
Example 1: A 70-year-old postmenopausal woman presents with a gradual loss of height and back pain.DEXA scan reveals significantly reduced bone mineral density, consistent with osteoporosis.The patient is started on bisphosphonate therapy and advised on dietary and exercise modifications., A 65-year-old male patient with a history of long-term steroid use undergoes a DEXA scan which shows osteopenia. The physician prescribes calcium and vitamin D supplements and closely monitors bone density., A 55-year-old female with a family history of osteoporosis and recent fracture undergoes a comprehensive bone health assessment, including DEXA scan and laboratory tests.The results confirm osteoporosis, prompting initiation of medication and lifestyle interventions.
Complete patient history including family history of osteoporosis, risk factors (e.g., steroid use, menopause), symptoms (e.g., back pain, loss of height), physical examination findings, bone mineral density (BMD) results (T-score, Z-score), and any relevant laboratory test results (e.g., serum calcium, vitamin D levels).
** This code is used for osteoporosis cases where there is no current pathological fracture.Always consider the patient's history and clinical presentation to ensure accurate coding.
- Payment Status: Active
- Specialties:Endocrinology, Rheumatology, Internal Medicine, Geriatrics, Orthopedics
- Place of Service:Office, Outpatient Hospital, Clinic