2025 ICD-10-CM code M84.561A
(Active) Effective Date: N/A Revision Date: N/A Musculoskeletal System Disorders - Osteopathies and chondropathies Chapter 13: Diseases of the musculoskeletal system and connective tissue Feed
Pathological fracture in neoplastic disease of the right tibia, initial encounter.
Modifiers may be used to indicate specific circumstances of service delivery (e.g., place of service, anesthesia, or other qualifying modifiers).Consult your local payer guidelines for specific allowed modifiers.
Medical necessity is established by the presence of a pathological fracture in the right tibia secondary to a neoplastic condition.The fracture requires intervention to alleviate pain, restore stability to the leg, and prevent further complications. Documentation must clearly demonstrate the causal relationship between the neoplasm and the fracture. Treatment is deemed medically necessary to improve the patient's functional status and quality of life.
The clinical responsibility involves a comprehensive assessment of the patient by a physician, including obtaining a detailed medical history, performing a physical examination focusing on the affected limb, ordering and interpreting imaging studies (X-rays, MRI, CT, bone scans, PET scans), laboratory tests (for tumor markers and other relevant investigations), and potentially performing a bone biopsy.The physician must determine the most appropriate treatment plan, which could include pain management (analgesics), fracture stabilization (casting), treatment of the underlying neoplastic disease (such as chemotherapy or radiation therapy), physical therapy, and/or surgical intervention to repair the fracture.
- Chapter 13: Diseases of the musculoskeletal system and connective tissue
- M80-M94 (Osteopathies and chondropathies)
In simple words: This code is used when someone breaks their right shinbone (tibia) because of a tumor, not an accident.It's for the first time this fracture is diagnosed and treated.
This code signifies the initial encounter for a pathological fracture (fracture caused by a pre-existing disease, not trauma) located in the right tibia due to a neoplastic (cancerous or benign tumor) condition.The diagnosis requires a thorough patient history, physical examination assessing range of motion, imaging studies (X-rays, MRI, CT, PET scan, bone scan), blood tests for neoplasm markers, and potentially a bone biopsy. Treatment may involve analgesics for pain management, casting for fracture stabilization, physical therapy to improve range of motion and muscle strength, treatment of the underlying neoplasm, and/or surgical fracture repair.
Example 1: A 65-year-old female with a history of metastatic breast cancer presents with pain and swelling in her right leg. Imaging reveals a pathological fracture of the right tibia.The code M84.561A is used for the initial encounter., A 72-year-old male with multiple myeloma is admitted to the hospital after falling and fracturing his right tibia.Radiographs confirm a pathological fracture. This is the initial encounter, so M84.561A is appropriate., A 58-year-old female with osteosarcoma of the right tibia presents with increasing pain and instability.Radiographs reveal a pathological fracture.This is her initial presentation for the fracture, therefore M84.561A is used.
* Detailed patient history including the history of the underlying neoplasm.* Physical examination findings, specifically the assessment of the right leg and the range of motion.* Radiographic images (X-rays, CT, MRI, PET scan) confirming the fracture and its location.* Results of blood tests assessing tumor markers and other relevant labs.* Results of bone biopsy if performed.* Documentation of the treatment plan, including pain management, fracture stabilization, and the management of the underlying neoplastic disease.
** This code is specific to the initial encounter for the fracture.Subsequent encounters for the same fracture will require different codes (M84.561D, G, K, P, S depending on the healing process).
- Payment Status: Active
- Specialties:Orthopedic Surgery, Oncology, Radiology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office