Stress fracture, right foot, subs for fx w malunion

This code signifies a stress fracture of the right foot that has healed in an imperfect alignment, resulting in a malunion. The patient is currently receiving routine care during the healing phase of this previously diagnosed and treated stress fracture.

Apply this code when a patient presents for follow-up care, such as cast changes, physical therapy, or medication management, for a right foot stress fracture that has developed a malunion. Documentation should clearly indicate a stress fracture, its location in the right foot, evidence of malunion, and that the encounter is for subsequent care.

• Ensure documentation specifies "right foot" and "stress fracture" to differentiate from other fracture types or locations.
• The "P" seventh character indicates a subsequent encounter for a fracture with malunion; do not use for initial treatment or routine healing without malunion.
• Code also any associated pain or functional limitations if documented and clinically relevant.