Stress fracture, right tibia, subs for fx w malunion

This code indicates a stress fracture of the right tibia that is currently healing abnormally, resulting in a malunion. It signifies that the patient is receiving active treatment for the complications arising from this improperly healed fracture.

Apply this code when documentation specifies a stress fracture of the right tibia with evidence of malunion, and the patient is undergoing follow-up care or treatment for this specific complication. This includes scenarios where surgical correction of the malunion is being planned or performed, or conservative management for the malunion is ongoing.

• Ensure documentation clearly states "malunion" and specifies the right tibia.
• Do not use this code for nonunion; a different subcategory (M84.4-) exists for nonunion.
• Always sequence this code as a primary diagnosis when the malunion is the reason for the encounter, or as a secondary diagnosis if the malunion is a co-morbidity affecting treatment of another condition.