Pathological fracture, right ankle, subs for fx w delay heal

This code signifies a fracture of the right ankle that occurred due to an underlying disease process, rather than trauma. The patient is currently receiving follow-up care for this pathological fracture, and the healing process is progressing slower than expected. This indicates a complication in the bone repair.

Apply this code when documentation specifies a pathological fracture of the right ankle and the patient is in a subsequent phase of care where delayed healing is noted. This typically applies after initial treatment, during ongoing management of the fracture. Supporting documentation would include physician notes detailing the pathological nature of the fracture, the right ankle location, and explicit mention of delayed union or healing.

• Ensure documentation clearly distinguishes between a pathological fracture and a traumatic fracture.
• Verify the laterality (right ankle) is explicitly stated in the medical record.
• Confirm the encounter is for subsequent care and that delayed healing is specifically documented, not just routine follow-up.