M97 — Periprosthetic fracture around internal prosthetic joint
ICD-10-CM codes M97 cover periprosthetic fracture around internal prosthetic joint, within diseases of the musculoskeletal system and connective tissue. The block holds 54 codes across 1 category, of which 36 are billable and 18 are header codes that cannot be submitted on a claim. 54 of them (100%) require a 7th character.
The 7th character in M97
A code in this block is not complete without its 7th character, and a missing one is a rejected claim rather than a denied one: the clearinghouse never passes it on. 54 of the 54 codes here take one.
- A
- initial encounter
- D
- subsequent encounter
- S
- sequela
Risk adjustment in M97
0 codes in this block map to a CMS-HCC, which means the diagnosis carries a risk-adjustment payment when it is documented and coded. Under-coding here is money left on the table; over-coding here is what audits are for.
- HCC 402 Hip Fracture/Dislocation
What else to watch in M97
- 40 codes are laterality-specific. They come in left and right pairs, and the pair is mutually exclusive on a single site: coding both without a bilateral code is a contradiction a scrubber should catch before the payer does.
- 36 codes are named in Medicare coverage policies. An LCD or NCD lists them as supporting medical necessity, or explicitly as not supporting it. Which applies depends on the MAC for your state.