Stress fracture, left femur, subs for fx w malunion

This code signifies a stress fracture located in the left femur that is currently undergoing treatment for a malunion. A malunion indicates that the fracture has healed, but in an unsatisfactory or misaligned position. This specific code is used when the patient is receiving follow-up care for this improperly healed stress fracture.

This code is appropriate for encounters where a patient is being managed for a previously diagnosed and treated stress fracture of the left femur that has healed incorrectly. Documentation should clearly state "malunion" and specify the left femur as the site of the stress fracture. This code is used for subsequent encounters after the initial treatment of the fracture.

• Ensure documentation explicitly states "malunion" and not just "nonunion" or "delayed healing," as these have different codes.
• Verify the laterality (left femur) is clearly documented; incorrect laterality is a common coding error.
• This code requires an additional code for any associated complications or external causes, if applicable.