Pathological fracture, right tibia, subs for fx w routn heal

This code signifies a fracture of the right tibia that occurred due to a pre-existing disease process, rather than trauma. The patient is currently in a follow-up phase where the fracture is healing as expected without complications.

Apply this code when documentation indicates a patient is receiving ongoing care for a pathological fracture of the right tibia that is progressing to routine healing. This is typically used for follow-up visits after initial treatment, where the focus is on monitoring healing. Documentation should specify "pathological fracture," "right tibia," and indicate a "subsequent encounter" with "routine healing."

• Ensure the documentation clearly states the fracture is "pathological" and not traumatic.
• Verify the laterality (right tibia) is explicitly documented.
• Confirm the encounter is for follow-up care and the healing is considered "routine" or "uncomplicated."