Pathological fracture, r shoulder, subs for fx w malunion

This code signifies a fracture of the right shoulder that occurred due to an underlying disease process, rather than trauma. It indicates that the patient is receiving follow-up care for this pathological fracture, and the fracture has healed improperly, resulting in a malunion.

Apply this code for patients presenting for ongoing treatment of a previously diagnosed pathological fracture of the right shoulder that has healed in a misaligned position. Documentation should clearly state "pathological fracture," specify the right shoulder, and indicate "malunion" during a subsequent encounter.

• Ensure documentation explicitly states "pathological fracture" and not just a simple fracture.
• Verify the laterality (right shoulder) is clearly documented.
• Confirm the encounter type is "subsequent" and that "malunion" is noted as the outcome of the fracture healing.