Stress fracture, left fibula, subs for fx w malunion

This code signifies a stress fracture of the left fibula that has healed improperly, resulting in a malunion. The patient is currently receiving care for this specific complication, indicating ongoing treatment or follow-up for the malunited fracture.

Apply this code when documentation clearly indicates a stress fracture of the left fibula with evidence of malunion, and the patient is seen for subsequent treatment related to this condition. This includes follow-up appointments, physical therapy, or surgical intervention for the malunion. Documentation should specify "malunion" and "subsequent encounter."

• Ensure documentation explicitly states "malunion" and "subsequent encounter" for the left fibula stress fracture.
• Do not use this code for initial encounters or for nonunion; specific codes exist for those scenarios.
• Verify laterality (left fibula) is clearly documented to avoid coding errors.