Maxillary fracture, unspecified side, 7thD

This code signifies a fracture of the maxilla (upper jaw bone) where the specific side of the fracture is not documented. The "D" seventh character indicates that the patient is receiving follow-up care for the fracture during its routine healing phase, after the initial treatment has been provided.

Use this code for subsequent encounters when a patient is being monitored for an unspecified maxillary fracture that is healing without complications. Documentation should clearly state "maxillary fracture, unspecified side" and indicate a follow-up visit for routine healing, such as "follow-up for maxillary fracture, healing well."

• Ensure documentation specifies "unspecified side" if the laterality is not known; otherwise, use a more specific code.
• The "D" seventh character is appropriate for routine follow-up care; use "G" for delayed healing or "K" for nonunion.
• Confirm that the encounter is not for initial treatment (use "A") or for a complication of the fracture.