Stress fracture, right tibia, subs for fx w delay heal

This code signifies a stress fracture in the right tibia that is currently undergoing treatment for delayed healing. It indicates that the patient has previously received initial care for this fracture and is now in a subsequent phase of management due to slower-than-expected bone repair.

Apply this code when documentation confirms a right tibial stress fracture that is not healing as anticipated, requiring ongoing medical intervention. This is appropriate for follow-up visits where the physician is monitoring the fracture's progress and addressing the delayed healing. Supporting documentation would include physician notes detailing the stress fracture, its location, and explicit mention of delayed healing or non-union.

• Ensure the "G" seventh character (subsequent encounter for fracture with delayed healing) is appropriate for the patient's current phase of care.
• Distinguish from initial encounters (A) or subsequent encounters for routine healing (D).
• Verify laterality (right tibia) is clearly documented to avoid coding errors.