M84.561A: Pathological fracture in neoplastic disease, right tibia, initial encounter for fracture

M84.561A, pathological fracture in neoplastic disease, right tibia, initial encounter for fracture, is listed as a covered diagnosis in 3 Medicare billing and coding articles that apply to 70 HCPCS Level II codes, including J0897 (Injection, denosumab, 1 mg), Q5136 (Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg), Q5157 (Injection, denosumab-bmwo (stoboclo/osenvelt), biosimilar…). 47 of these codes have a 2026 DMEPOS fee schedule amount; L1844 pays $1,865.51 to $2,436.24 depending on the state. The articles come from 2 Medicare contractors. A listed diagnosis supports medical necessity only; coverage still depends on the LCD's criteria and on documentation in the medical record.

HCPCS Level II codes with M84.561A as a covered diagnosis

CodeDescriptionMedicare coverageDMEPOS fee 2026 (state range)Articles listing it
J0897Injection, denosumab, 1 mgCarrier judgment—1
Q5136Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mgCarrier judgment—1
Q5157Injection, denosumab-bmwo (stoboclo/osenvelt), biosimilar, 1 mgCarrier judgment—1
Q5158Injection, denosumab-bnht (bomyntra/conexxence), biosimilar, 1 mgCarrier judgment—1
Q5159Injection, denosumab-dssb (ospomyv/xbryk), biosimilar, 1 mgCarrier judgment—1
Q5162Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mgCarrier judgment—1
Q5165Injection, denosumab-mobz (oziltus), biosimilar, 1 mgCarrier judgment—1
Q5166Injection, denosumab-desu (osvyrti/jubereq), biosimilar, 1 mgCarrier judgment—1
Q5167Injection, denosumab-qbde (enoby/xtrenbo), biosimilar, 1 mgCarrier judgment—1
Q5171Injection, denosumab-mobz (boncresa), biosimilar, 1 mgCarrier judgment—1
L1844Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricatedCarrier judgment$1,865.51–$2,436.241
L1860Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (sk)Carrier judgment$1,233.07–$1,985.941
L1846Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricatedCarrier judgment$1,283.72–$1,960.171
L1834Knee orthosis, without knee joint, rigid, custom fabricatedCarrier judgment$892.02–$1,808.361
L1832Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertiseCarrier judgment$698.63–$1,618.031
L1840Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricatedCarrier judgment$1,056.60–$1,606.151
L1843Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertiseCarrier judgment$1,076.26–$1,183.901
L1845Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertiseCarrier judgment$939.24–$1,180.511
L1833Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelfCarrier judgment$455.16–$1,087.161
L1851Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelfCarrier judgment$600.78–$959.091
L1852Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelfCarrier judgment$573.13–$940.491
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis onlyCarrier judgment$429.42–$904.141
L1847Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertiseCarrier judgment$689.92–$827.891
L1848Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelfCarrier judgment$689.92–$827.891
L1850Knee orthosis, swedish type, prefabricated, off-the-shelfCarrier judgment$205.78–$408.531

45 more codes are listed. See every code with payment by region in Caduvo.

Medicare policy articles listing M84.561A

A diagnosis listed as covered in a billing and coding article supports medical necessity for the article's codes; it does not guarantee payment. Coverage depends on the LCD's criteria, the contractor's jurisdiction and documentation in the medical record.

Other M84 diagnoses (Disorder of continuity of bone)

Frequently asked questions

Does Medicare cover M84.561A (Pathological fracture in neoplastic disease, right tibia…)?

Medicare covers items and services, not diagnoses. 3 Medicare billing and coding articles list M84.561A as a covered diagnosis for 70 HCPCS Level II codes: the diagnosis can support medical necessity for those codes, but payment still depends on the LCD's coverage criteria and the medical record.

Which HCPCS codes can be billed with ICD-10 M84.561A?

The Level II codes from the policies most specific to this diagnosis are J0897 (Injection, denosumab, 1 mg, 1 article); Q5136 (Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg, 1 article); Q5157 (Injection, denosumab-bmwo (stoboclo/osenvelt), biosimilar…, 1 article); Q5158 (Injection, denosumab-bnht (bomyntra/conexxence)…, 1 article); Q5159 (Injection, denosumab-dssb (ospomyv/xbryk), biosimilar, 1 mg, 1 article). Code choice depends on the item supplied; check each code's descriptor.

What does Medicare pay for equipment billed with M84.561A?

Under the 2026 DMEPOS fee schedule (non-rural state fees): L1844 $1,865.51 to $2,436.24; L1860 $1,233.07 to $1,985.94; L1846 $1,283.72 to $1,960.17; L1834 $892.02 to $1,808.36. Medicare pays 80% of the allowed amount after the Part B deductible.

Which Medicare policy articles list M84.561A?

A52399 (Billing and Coding: Denosumab (Prolia®, Xgeva®, Jubbonti®) and biosimilars); A52465 (Knee Orthoses - Policy Article); A57311 (Billing and Coding: Physical Therapy - Home Health).

What is ICD-10-CM code M84.561A?

M84.561A is the ICD-10-CM code for pathological fracture in neoplastic disease, right tibia, initial encounter for fracture, in category M84 (Disorder of continuity of bone), chapter 13: Diseases of the musculoskeletal system and connective tissue.

Next steps

Sources: CMS Medicare Coverage Database billing and coding articles (covered ICD-10 code lists and HCPCS links); ICD-10-CM FY2026; CMS HCPCS Level II release October 2026; CMS DMEPOS fee schedule 2026 (non-rural state fees). Not billing or legal advice.

Chapter 13: Diseases of the musculoskeletal system and connective tissue · All diagnoses · HCPCS lookup