Stress fracture, right tibia, initial encounter for fracture

This code signifies a stress fracture affecting the right tibia, which is a hairline crack in the bone resulting from repetitive stress rather than a single traumatic event. It indicates the patient is receiving initial active treatment for this specific fracture.

Apply this code when documentation clearly states a stress fracture of the right tibia and the patient is in the acute phase of treatment, such as initial evaluation, casting, or surgical intervention. Supporting documentation should include imaging reports confirming the stress fracture and physician notes detailing the initial management plan.

• Ensure laterality (right) is explicitly documented.
• Confirm "initial encounter" status; subsequent care would use a different seventh character.
• Differentiate from pathological fractures (M84.4-) or other types of tibia fractures (S82.-).