LeFort I fracture, subs encntr for fracture with nonunion

This code describes a patient who is receiving active treatment for a LeFort I fracture that has failed to heal properly, resulting in a nonunion. A LeFort I fracture involves the horizontal separation of the maxilla from the pterygoid plates and nasal septum, typically occurring at the level of the nasal floor. Nonunion indicates that the bone ends have not united and healing has ceased.

Use this code for follow-up encounters where a patient with a previously diagnosed LeFort I fracture is being managed for a confirmed nonunion. This includes visits for surgical intervention to address the nonunion (e.g., bone grafting, internal fixation revision) or ongoing medical management. Documentation should clearly state "nonunion" of the LeFort I fracture and indicate that the encounter is for active treatment of this complication.

• Ensure documentation explicitly states "nonunion" of the LeFort I fracture; "delayed union" is a different condition and coded elsewhere.
• This code is for subsequent encounters; an initial encounter for a LeFort I fracture would use a different code (S02.411A).
• Always sequence this code first when the nonunion is the primary reason for the encounter, followed by any external cause codes if applicable.