Maxillary fracture, right side, 7thB

This code signifies a fracture of the right upper jaw bone (maxilla) where the skin and soft tissue overlying the fracture are broken, exposing the bone to the outside environment. It indicates the initial treatment or evaluation for this specific injury.

Use this code for patients presenting with a newly diagnosed open fracture of the right maxilla, such as from trauma sustained in an accident or assault. Documentation should clearly state "open fracture," specify the "right maxilla," and indicate that this is the first encounter for definitive treatment.

• Ensure documentation explicitly states "open" to differentiate from closed fractures.
• Verify laterality (right) is clearly documented; separate codes exist for left or unspecified sides.
• This "initial encounter" code is used for the period of active treatment for the injury, not just the first visit.