Stress fx, unsp tibia and fibula, subs for fx w nonunion

This code signifies a stress fracture affecting an unspecified bone within the tibia and fibula region, which has failed to heal properly and is currently being managed during a subsequent encounter. A stress fracture is a small crack in a bone, often caused by repetitive stress or overuse, rather than a single traumatic event. Nonunion indicates that the fracture shows no signs of healing after a reasonable period.

Apply this code when a patient presents for ongoing treatment of a previously diagnosed stress fracture of the tibia or fibula that has progressed to nonunion. Documentation should clearly state "stress fracture," specify the location as tibia/fibula (even if unspecified further), and explicitly mention "nonunion" and that this is a "subsequent encounter" for care related to the fracture. This code is appropriate for follow-up visits, cast changes, or evaluations for surgical intervention for the nonunion.

• Ensure documentation specifies "stress fracture" and not a traumatic fracture, as different codes apply.
• Verify the encounter type is "subsequent" (e.g., follow-up, cast change) and not an initial encounter for the nonunion.
• Distinguish from malunion (M84.4-) where the fracture has healed but in an unsatisfactory position.