Stress fracture, left tibia, subs for fx w malunion

This code signifies a stress fracture of the left tibia that is currently undergoing treatment for a malunion. A malunion indicates that the fracture has healed, but in an unsatisfactory or misaligned position, requiring ongoing management.

Apply this code when a patient presents for follow-up care, rehabilitation, or further intervention (e.g., surgical correction) for a previously diagnosed left tibial stress fracture that has healed incorrectly. Documentation should clearly state "malunion" and specify the left tibia as the affected site.

• Ensure documentation explicitly states "malunion" and not just "nonunion" or "delayed union," as these have different codes.
• Verify laterality (left tibia) is clearly documented; separate codes exist for the right and unspecified tibia.
• This "P" seventh character indicates a subsequent encounter for a fracture with malunion; do not confuse with "K" (nonunion) or "D" (routine healing).