Stress fracture, right fibula, subs for fx w malunion

This code signifies a stress fracture of the right fibula that has previously been treated but has healed improperly, resulting in a malunion. The patient is currently receiving care for this established malunion.

Apply this code when a patient presents for ongoing management or treatment of a right fibular stress fracture that has healed in an anatomically incorrect position. Documentation should clearly state "malunion" and specify the right fibula as the affected site, along with the "subsequent encounter" status.

• Ensure documentation explicitly states "malunion" and not just "nonunion" or "delayed union."
• Verify the laterality (right fibula) is clearly documented.
• Confirm this is a subsequent encounter for the fracture, not an initial treatment.