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

This code signifies a stress fracture affecting an unspecified bone of the lower leg (tibia or fibula) that is currently healing with an abnormal alignment of the bone fragments. The "subsequent encounter" indicates the patient is receiving routine care during the healing phase, and "malunion" specifies that the fracture is not healing correctly, resulting in deformity.

Apply this code when a patient presents for follow-up care of a previously diagnosed stress fracture of the tibia or fibula, and clinical or radiological findings confirm that the fracture is healing in a misaligned position. Documentation should clearly state "stress fracture," "tibia" or "fibula" (if unspecified, this code is appropriate), "subsequent encounter," and "malunion."

• Ensure documentation explicitly states "stress fracture" to differentiate from acute traumatic fractures.
• Verify that the encounter is for ongoing care of the fracture, not the initial treatment or sequelae.
• Distinguish "malunion" from "nonunion" (M84.369N), which indicates a complete failure of the bone to heal.