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).
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.
- Diseases of the musculoskeletal system and connective tissue (M00-M99)
- Disorders of bone density and structure (M80-M85)Osteopathies and chondropathies (M80-M94)
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.
- Specialties:Orthopedics, Endocrinology, Oncology (depending on underlying disease)
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Physician's Office, Independent Clinic