( PDF ) Rev Osteoporos Metab Miner. 2010; 2 (2): 89

Manuel Sosa Henríquez, Emilio de Miguel Ruiz, Abdón Arbelo Rodríguez, Antonia Rodríguez Hernández, Agustín García Bravo
Grupo Canario de Trabajo en Osteoporosis


To the Director:

The fracture of the proximal extremity of the femur, known also as a hip fracture, constitutes the most serious clinical complication of osteoporosis1, leading to an increase both in the morbidity and the mortality of the patients who suffer it2-4. Practically all hip fractures are admitted to hospital, where they are mostly dealt with by surgical intervention5. For many years, in all the hospitals in our country, a system of coding for diseases is applied, based on the international classification of diseases, or ICD • 9 •6. These codes are applied both in the clinical history and in the databases of hospital archives
It might be thought that the collection of epidemiological data on hip fractures is simple, since by practically all cases being admitted to hospitals, they would be easily identifiable7. However, we believe that in reality this is not the case, and that it is possible that we are losing information on the true prevalence both of fractures of the hip and on osteoporosis and vertebral fractures, because the current coding allows many options.

Thus, for example, with a fracture of the femoral neck in an older woman of 80 years who slips and falls on the floor, if the slip is recorded as the cause of the fall, it is coded as E885.9, and if it is not specified how the fracture was produced, the code E887, “fracture with no specified cause”, is used. However, if the practitioner considers that the fracture is the consequence of osteoporosis, the same fracture could be coded as 733.14, “pathological fracture of the femoral neck”, having to be preceded by the code 733.00, which corresponds to “non-specific osteoporosis”. We see, therefore, that the same fracture can be coded in three different ways, all correct.
The same confusion can be observed in the case of vertebral fracture, which again can be coded as 733.00 (“osteoporosis”) and then as 733.13, “pathological fracture of vertebrae”. However, if the clinician indicates only a vertebral fracture and does not specify the existence of osteoporosis, the corresponding code is 805.8 (“non-specified vertebral fracture, closed”). To complete the confusion, it can also be coded as 733.00, and, therefore be considered as “osteoporosis” when the clinical report has the terms “thinned vertebra”, “cuneiform degeneration of the vertebra”, or “cuneiform vertebra”, which would possibly be better termed as vertebral fractures. Finally, if the diagnosis is given as “osteoporosis” it can be coded as 733.00 (“non-specified osteoporosis”), 733.01 (“senile osteoporosis”), 733.02 (“idiopathic osteoporosis”), 733.03 (“osteoporosis due to disuse”) and 733.09 (“other”).
In this letter to the Director, we would like to bring attention to the fact that there probably exist very many ways of coding both osteoporosis and fragility fractures. And this makes us reflect that, at the time of carrying out an epidemiological study on any of these processes in a hospital environment, it is necessary to take into account each and every one of the existing possibilities for coding these processes, because it is certain that, with any other approach, cases would be lost.
Finally, as a result of these comments, we put a proposal to try to unite clinicians in ensuring that the diagnostic expression used reaches the highest possible level of specificity, so that, in coding the clinical histories for both hip and vertebral fractures, we can achieve the single, most precise and specific code, from among those that exist.
1. Duque G, Demontiero O, Troen BR. Prevention and treatment of senile osteoporosis and hip fractures. Minerva Med 2009;100:79-94.
2. Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 2009;301:513-21.
3. Ioannidis G, Papaioannou A, Hopman WM, Akhtar-Danesh N, Anastassiades T, Pickard L, et al. Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study. CMAJ 2009;181:265-71.
4. Vestergaard P, Rejnmark L, Mosekilde L. Loss of life years after a hip fracture. Acta Orthop 2009;80:525-30.
5. Sosa M, Segarra MC, Hernández D, González A, Limiñana JM, Betancor P. Epidemiology of proximal femoral fracture in Gran Canaria (Canary Islands). Age Ageing 1993;22:285-8.
6. CIE 9. Clasificación Internacional de las enfermedades. 9ª revisión Modificación Clínica. 6ª Edición. Información y Estadísticas Sanitarias 2008. Ministerio de Sanidad y Consumo. Madrid. 2008.
7. Icks A, Haastert B, Wildner M, Becker C, Meyer G. Trend of hip fracture incidence in Germany 1995-2004: a population-based study. Osteoporos Int 2008;19:1139-45.