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Documentation of communication that a fracture occurred and that the patient was or should be tested or treated for osteoporosis (OP)

CPT4 code

Name of the Procedure:

Documentation of Communication for Fracture and Osteoporosis Testing/Treatment


This procedure involves healthcare providers documenting their communication with a patient who has experienced a fracture, informing them about the presence of the fracture and the need for osteoporosis testing or treatment.


This documentation ensures that patients are made aware of their fracture and the potential underlying condition of osteoporosis. The goal is to prompt timely osteoporosis diagnosis and management, preventing future fractures and complications related to bone health.


  • Suspected or confirmed fracture in a patient.
  • Patients with risk factors for osteoporosis (e.g., postmenopausal women, older adults, individuals with a family history of osteoporosis, those with a prior history of fractures).


  • No specific preparation is required for the documentation itself.
  • Healthcare providers should be prepared with all relevant patient medical history, current medications, and fracture details.

Procedure Description

  1. Identification: Confirm the patient's fracture through medical imaging or physical examination.
  2. Communication: Discuss the fracture diagnosis with the patient, explaining its implications.
  3. Osteoporosis Consideration: Inform the patient about the importance of testing for osteoporosis.
  4. Plan: Recommend appropriate osteoporosis diagnostic tests (e.g., DEXA scan) or treatments.
  5. Documentation: Record the details of the communication, including the discussion points, patient’s understanding, and their consent or refusal to follow-up actions.


Approximately 10-20 minutes, depending on the complexity of the patient's case and questions.


Can be performed in various healthcare settings, including hospitals, outpatient clinics, or doctor's offices.


  • Primary healthcare provider (physician, nurse practitioner, or physician assistant).
  • Additional support staff if needed.

Risks and Complications

  • Minimal risks associated with the communication and documentation itself.
  • Risk of miscommunication or misunderstanding, which can be mitigated through clear and thorough discussion.


  • Increased patient awareness and understanding of their health condition.
  • Early detection and treatment of osteoporosis, potentially reducing the risk of future fractures.
  • Comprehensive medical record keeping.


  • No physical recovery required from the documentation procedure.
  • Follow-up with osteoporosis testing or treatment as recommended by the healthcare provider.


  • Patients can seek second opinions regarding their fracture and osteoporosis management.
  • Discussing the risk of osteoporosis with a specialist (e.g., endocrinologist, rheumatologist) for further evaluation.

Patient Experience

  • Patients will engage in a detailed conversation about their fracture and the importance of osteoporosis management.
  • They can expect supportive care and clear instructions regarding the next steps.
  • Pain management related to the fracture will be addressed as part of the overall treatment plan.

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