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2025 ICD-10-CM code M84.661P

A pathologic fracture of the right tibia due to an underlying disease, with a subsequent encounter for malunion (abnormal healing).

Do not use this code for traumatic fractures or fractures caused by osteoporosis or neoplastic diseases. Code the underlying condition first.

Medical necessity is established by the presence of a pathological fracture due to a documented underlying disease and the need for treatment of the fracture malunion.

Diagnosis involves patient history, physical exam (range of motion, muscle strength), imaging (X-ray, MRI, CT, DXA scan), and lab tests (ESR). Treatment may include analgesics, bracing/splinting, nutritional supplements (calcium), lifestyle changes, physical therapy, treating the underlying disease, and/or surgery.

In simple words: This code describes a broken right shinbone (tibia) caused by a disease that weakened the bone.It indicates that the bone has healed incorrectly during a follow-up visit.

Pathological fracture in other disease, right tibia, subsequent encounter for fracture with malunion.This refers to a fracture of the right tibia caused by a disease process other than osteoporosis or a neoplastic disease, where the bone has not healed correctly, resulting in a malunion.

Example 1: A patient with Paget's disease of bone experiences a fracture of their right tibia.Follow-up examination reveals the fracture has healed with a malunion., A patient with osteomalacia suffers a pathological fracture of the right tibia. After several weeks, the treating physician determines the bone has healed in a malunion., A patient on long-term steroid therapy develops a pathological fracture of the right tibia.Subsequent imaging confirms a malunion of the fracture.

Documentation should include the underlying disease, details of the fracture, evidence of malunion from imaging studies, and treatment provided.

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