Maxillary fracture, left side, init

This code identifies a fracture of the left maxilla, which is the upper jaw bone. It specifies that the fracture is closed, meaning there is no open wound communicating with the fracture site, and that this is the initial encounter for treatment.

Use this code for a patient presenting for the first time for definitive treatment of a non-displaced or displaced fracture of the left maxilla, where the overlying skin and mucous membranes are intact. Documentation should clearly indicate a left-sided maxillary fracture, its closed nature, and that the patient is in the active treatment phase.

• Differentiate between initial, subsequent, and sequela encounters based on the patient's treatment phase.
• Ensure laterality (left vs. right) is clearly documented; if unspecified, an unspecified code should be used.
• Confirm the fracture is indeed closed; open fractures require a different code.