Stress fracture, right shoulder, subs for fx w malunion

This code signifies a stress fracture of the right shoulder that is currently healing with an abnormal alignment of the bone fragments. It indicates that the patient is receiving follow-up care for this previously diagnosed and treated fracture. Malunion implies that the bone has healed, but in a deformed or misaligned position.

Apply this code when documentation specifies a stress fracture of the right shoulder with malunion, and the patient is seen for ongoing management, evaluation, or treatment related to this healing complication. This code is appropriate for subsequent encounters after the initial treatment of the fracture. Supporting documentation should clearly state "stress fracture," "right shoulder," "malunion," and indicate a follow-up visit.

• Ensure documentation explicitly states "malunion" for the right shoulder stress fracture; otherwise, a nonunion or routine healing code may be more appropriate.
• Verify laterality (right shoulder) is clearly documented.
• This code is for subsequent encounters; use an initial encounter code for the first visit related to the fracture.