Documenting Osteoporosis

Documenting Osteoporosis

  • 11 Feb 0
  • Share

Osteoporosis is a disease of the bones common to the population we treat.  Osteoporosis can affect both men and women and woman can lose up to 20% of their bone mass in the years after menopause.

There are two categories of Osteoporosis:  primary and secondary.  Primary osteoporosis includes postmenopausal, senile and idiopathic.  Secondary osteoporosis is caused by various medical conditions including chronic kidney disease, rheumatoid arthritis and hyperthyroidism.

Coding for osteoporosis is not difficult if the documentation indicates which type of osteoporosis is present.  The two most common codes used are 733.01 (postmenopausal and senile OP) and 733.00 (Osteoporosis unspecified).  For coding purposes, when documenting osteoporosis the provider should state which type of osteoporosis is present.  To follow ICD-9 guidelines, if the documentation states only osteoporosis, the coder has no choice but to assign 733.00.

Most fractures in the elderly are fragility fractures related to osteoporosis.  As such, these are known as pathologic fractures (other conditions cause pathologic fractures, such as cancer) and if a fracture is present, it is imperative to document if it is due to osteoporosis (i.e., pathologic).  Not all fractures in the presence of osteoporosis are pathologic, so documentation should be clear.

Some osteoporotic fractures, such as vertebral fractures (733.13) remain symptomatic for months or longer.  In such cases, the fracture may continue to be coded if the provider a) documents the fracture as pathologic and b) treatment is be aimed at the effects of the fracture and not only treatment for osteoporosis.