Stress fracture, right ankle, subs for fx w malunion

This code signifies a stress fracture in the right ankle that is currently undergoing treatment for a malunion. A malunion indicates that the fracture has healed in an unsatisfactory position, potentially leading to pain, deformity, or functional impairment. This encounter is for ongoing management of this complicated healing process.

Apply this code when a patient presents for follow-up care, evaluation, or treatment related to a previously diagnosed right ankle stress fracture that has healed incorrectly. Documentation should clearly state "malunion" and specify the right ankle and the stress fracture etiology. This code is appropriate for subsequent visits after the initial treatment of the malunion has begun.

• Ensure documentation specifies "malunion" and not just "nonunion" or "delayed healing," as these have different codes.
• Always confirm laterality (right ankle) is clearly documented.
• This code requires an external cause code (e.g., W00-Y38) if the stress fracture was due to an external cause, or a Z code for activity if applicable.