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2025 ICD-10-CM code M84.474A

Pathological fracture of the right foot. This code applies to the initial encounter for a pathologic fracture.

Do not use M84.474A if the fracture is the result of trauma.Use the appropriate traumatic fracture code instead. Ensure documentation clearly establishes the fracture as pathological. For subsequent encounters for this fracture, use the appropriate 7th character to indicate subsequent care for fracture with routine healing, delayed healing, nonunion, or malunion.

Medical necessity for M84.474A hinges on the pathological nature of the fracture. The medical record must clearly indicate that the fracture is due to a documented underlying medical condition, differentiating it from a traumatic fracture. Documentation should include the symptoms, physical exam findings, imaging results (such as x-rays or other relevant scans), and the physician’s assessment connecting the fracture to the underlying disease process.

In simple words: A broken right foot caused by a medical condition, not an injury. This code is used when someone first seeks care for the broken bone.

A fracture of the right foot caused by an underlying disease process, such as osteoporosis, infection, or tumor, rather than direct trauma. This code is specifically for the initial encounter for the fracture.

Example 1: A 65-year-old female with osteoporosis presents with sudden pain in her right foot after standing up from a chair. An x-ray reveals a fracture in the metatarsal bone.As this is her first visit for this fracture, M84.474A is used., A patient with bone cancer experiences sharp pain in their right foot while walking. Imaging shows a pathological fracture of the calcaneus. This is their initial visit for this condition, so M84.474A is applied., A patient with a bone infection in their right foot stubs their toe and experiences significant pain.X-rays reveal a fracture related to the weakened bone from the infection.Since it is the initial encounter for the fracture, M84.474A is the correct code.

Documentation should support the diagnosis of a pathological fracture by describing the underlying disease process and the presence of the fracture in the right foot. Imaging reports confirming the fracture are essential. The documentation should also explicitly state that this is the initial encounter for the fracture.

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