ICD-10-CM This is a 70-year-old lady with complaints of low back pain with radia
ID: 3504686 • Letter: I
Question
ICD-10-CM
This is a 70-year-old lady with complaints of low back pain with radiation down her right leg to her foot. This pain has been progressively worse over the last several months. She is to the point that she is unable to move. She was admitted and X rays were taken. Her X-rays show severe compression fractures of the lumbar vertebra due to her senile osteoporosis. Past medical history includes coronary artery disease and hypertension She had CABG two years ago and PTCA with cardiac stents placed three years ago.
Which conditions will you code? What are the codes? Provide your pathway.
Explanation / Answer
Senile osteoporosis is a disease of bone that leads to increased risk of fracture.
Bone density is reduced due to aging & also due to calcium deficiency .So the bone structure deteriorates & becomes very fragile.
In this case the treatment should be Alendronate since she is in the postmenopausal group along with vitamin D & calcium supplements.
Other treatment choices are Residronate, Strontium & Zoledronic acid.
Also as precautionary measure, patient should be asked to rest & not involve in heavy work that can cause her fracture.