2025 ICD-10-CM code Z87.311
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status and contact with health services - Personal history of diseases of the musculoskeletal system and connective tissue Chapter 21: Factors influencing health status and contact with health services Feed
Personal history of a healed, non-traumatic pathological fracture (other than osteoporosis or stress fracture).
The medical necessity for coding Z87.311 is to accurately document the patient's medical history for risk stratification, treatment planning, and to inform future healthcare decisions. It contributes to comprehensive patient care.
The clinical responsibility involves documenting the patient's medical history accurately, including the type of fracture, cause, and healing status.This information is relevant for risk assessment, treatment planning, and future healthcare decisions.
- Chapter 21: Factors influencing health status and contact with health services
- Z87.311 falls under the broader category Z87 (Personal history of other diseases and conditions) and the subcategory Z87.3 (Personal history of diseases of the musculoskeletal system and connective tissue).
In simple words: This code means the patient had a broken bone in the past that wasn't caused by an accident or injury, and it's completely healed now.Doctors use this code to keep track of the patient's medical history.
This ICD-10-CM code signifies a documented history of a healed fracture that was not caused by trauma, osteoporosis, or stress.It represents a past medical condition that may influence current healthcare decisions or management.The fracture must be fully healed and not currently causing symptoms.This code is used to document the patient's medical history and might be relevant for risk assessment or future care planning.It is crucial to differentiate this code from codes for traumatic fractures (Z87.81), osteoporosis fractures (Z87.310), and stress fractures (Z87.312).
Example 1: A 60-year-old patient presents for a routine checkup.During the history taking, it is revealed that the patient had a pathological fracture of the femur 10 years ago due to a bone tumor. The fracture healed completely after surgery and has not caused any problems since. Z87.311 is used to document this history., A 45-year-old patient is seen in the orthopedic clinic for persistent lower back pain.The physician finds no acute issues, but the patient mentions a past history of a compression fracture in the L2 vertebra that resulted from prolonged steroid use. The fracture healed without incident. Z87.311 is used to indicate this history., A 28-year-old patient undergoing pre-operative evaluation for a total knee replacement reports a childhood fracture of the tibia that resulted from a low-impact fall, which healed normally.The fracture was not caused by osteoporosis or stress.Z87.311 is appropriate to document this healed fracture.
Documentation should include the date of the fracture, the affected bone, the cause of the fracture (confirming it's pathological and not traumatic, osteoporotic, or stress-related), and evidence of complete healing (e.g., X-ray reports).
** This code is particularly useful in situations where a past fracture might influence the current clinical picture, such as risk assessment for future fractures, or treatment planning for conditions related to the previously fractured bone.
- Payment Status: Active
- Specialties:Orthopedics, Oncology, Rheumatology
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital