Stress fracture, left toe(s), subs for fx w malunion

This code signifies a stress fracture affecting one or more toes on the left foot that is currently healing with an abnormal alignment of the bone fragments. Malunion indicates that the fracture has healed, but the bone has united in a deformed position, potentially causing functional impairment or pain. This specific encounter is for ongoing treatment or management of this malunited stress fracture.

Apply this code when a patient presents for follow-up care, rehabilitation, or management of complications related to a stress fracture of the left toe(s) that has healed with malunion. Documentation should clearly state "malunion" and specify the left toe(s) as the affected site, along with an indication that this is not the initial treatment encounter.

• Ensure documentation explicitly states "malunion" and not just "nonunion" or "delayed union," as these have different codes.
• Verify the laterality (left) and the specific site (toe(s)) are clearly documented.
• This "P" seventh character indicates a subsequent encounter for a fracture with malunion; do not use for initial treatment or routine healing.