Stress fracture, right femur, subs for fx w malunion

This code signifies a stress fracture in the right femur that has previously been treated but has healed improperly, resulting in a malunion. It indicates that the patient is currently receiving care for the complications or ongoing management related to this poorly healed fracture.

Apply this code when documentation clearly states a stress fracture of the right femur with evidence of malunion, and the patient is in a subsequent phase of care (e.g., follow-up, rehabilitation, or treatment for malunion complications). This code is appropriate when the initial treatment for the stress fracture has concluded, and the current encounter addresses the sequelae of the malunion.

• Ensure documentation specifies "malunion" and not just "nonunion" or "delayed healing," as these have different codes.
• Verify the laterality (right femur) is explicitly stated in the medical record.
• Confirm the encounter is "subsequent" and not an initial treatment for a new fracture or the initial treatment for the stress fracture itself.