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Just a few months ago if you had asked me whether a person who falls from standing and breaks a hip had a traumatic fracture, I would have said yes.

There was an impact.
Therefore it was traumatic.
Most physicians would probably say the same.

As you can guess, that is not the right way to think about it.

And that mindset has real consequences for coding, quality, and reimbursement.

Why this matters

First, credit to Dr. John Kennedy and Brian Murphy whose Linkedin posts brought this to my attention.

When you look at the medical (non-surgical) DRGs around fractures, you will find two major groups based on what ICD-10-CM codes index to which DRGs.

Traumatic
DRGs 533 and 534 for fractures of femur without MCC and with MCC
DRGs 535 and 536 for fractures of hip and pelvis without MCC and with MCC

Pathological
DRGs 542 - 544 for pathological fractures and musculoskeletal and connective tissue malignancy without CC, with CC, and with MCC

(Make sure you can see the picture above. If not, scroll to the top of this email and click “read online”).

A few important points jump out. The traumatic DRGs only have two levels: without MCC and with MCC. The pathological group includes the typical three levels: without CC, with CC, and with MCC.

(Vocabulary reminder. The base DRG is the DRG without a CC or MCC.)

Although the traumatic base DRGs have higher weights than the pathological base DRG, the pathological CC DRG is higher than the traumatic base DRG - and CCs are relatively common in this population. The pathological MCC DRG is also higher weighted than the traumatic MCC DRGs.

If you’re unsure why that matters, I covered the reimbursement math in a previous newsletter. Short version: Higher weight means higher reimbursement.

Quality is also affected. The pathological non-base DRGs have longer geometric mean lengths of stay (GMLOS) compared to their traumatic counterparts. If your hospital tracks expected versus observed length of stay, a pathological assignment increases the expected stay (when a CC or MCC is present).

There are more impacts to quality measures which I’ll mention later.

Where most hospitals are missing out

A pathological fracture is a break in a bone that has been weakened by an underlying disease process, occurring with minimal or no trauma. These underlying diseases include metastatic cancer, primary bone tumors, infections such as osteomyelitis, Paget’s disease, hematological malignancies and… osteoporosis.

Osteoporosis-associated pathological fractures are the low hanging fruit as osteoporosis is very common. Bones affected by the other diseases are typically more front-of-mind for clinicians and hopefully are documented as pathological (but likely still a documentation opportunity).

There are two major issues with osteoporosis fractures:

1. Osteoporosis is present but missed on admission, OR the fracture is documented as traumatic rather than being due to / associated with the known osteoporosis.

2. Fragility fractures are under recognized.

Fr- what?
I know.
I had never heard of them either.
Neither had any of my fellow hospitalists I polled.

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What are fragility fractures?

Check the algorithm above.
(Again, make sure you can see the graphic. If not, scroll to the top of the email and click “read online”)

Most clinicians are aware of the right side of that algorithm - diagnosing osteoporosis by DEXA scan and FRAX score (fracture risk calculator). However, most are not familiar with the top left: Fragility fracture —> Osteoporosis.

So, what’s a fragility fracture?

A fragility fracture is a fracture which occurs with no associated trauma or with trauma equivalent to falling from a standing height or less. This is important because, as the algorithm suggests above, osteoporosis is diagnosed on the basis of the occurrence of a fragility fracture alone.
Period.
Regardless of DEXA scan.

This definition is supported by (at least) the World Health Organization (WHO), American College of Obstetricians and Gynecologists (ACOG), and American Academy of Orthopaedic Surgeons (AAOS) (sources below).

I also talked to two orthopedic surgeons who confirmed this concept.

This is pertinent to postmenopausal women.
But what about men?

Same.
In fact, mortality is higher in men than women.

The coding of pathological fractures due to osteoporosis will lead to M80- codes. Note that the term “fragility fracture” is included under the M80 header but the specific term is “osteoporosis with current fragility fracture.” So, coders still need the linkage to osteoporosis in documentation.

Why M80 codes are important for Quality Measures

There are no M80- codes included in the list of codes that trigger the CMS Hospital Acquired Condition for Falls and Trauma (HAC-05). Meaning, if a fall with a fracture occurs during a hospitalization and it is due to osteoporosis / fragility fracture and not trauma - then it will not be considered a HAC / the hospital will not get dinged if coded as such.

For Patient Safety Indicator 08 (In-Hospital Fall-associated Fracture Rate) a major update occured in 2025 where a majority of the M80 codes were removed. All upper extremity and lower extremity M80 codes were removed with the exception of femur M80 codes. So, the measure no longer includes non hip M80 fractures / only includes femur fracture subset.

Takeaways:

Look to see if osteoporosis is present for any patient who presents with a fracture. This can be supported by DEXA, imaging, previous documentation, or therapy such as use of bisphosphonates.

Look to see if the presentation fits the definition of a fragility fracture.

Be mindful of problem lists. Sometimes the chronic problem list includes “osteoporosis without current pathological fracture” which can create conflicting documentation if pulled into the current hospitalization.

If your clinicians pick diagnoses from dropdown menus rather than free text (such as EPIC’s problem-oriented-charting), make sure the correct terminology is available in the system.

For clinicians, if the fracture is associated with osteoporosis, document that link. For CDI specialists, consider querying for pathological fracture associated with osteoporosis if the above clinical indicators are present.

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Share your thoughts in the comments, or on Linkedin!

That’s all for now. Cheers,

Robert

Thank you to Laura Samson, RN BSN CCDS for editing this newsletter!

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