Fracture of vault of skull, subs for fx w delay heal

This code signifies a fracture of the cranial vault that is currently undergoing treatment for delayed healing. It indicates that the initial injury has occurred, and the patient is now in a subsequent phase of care where the bone union is not progressing at the expected rate.

Apply this code when a patient presents for follow-up care of a skull vault fracture, and the physician explicitly documents "delayed healing," "nonunion," or similar terminology indicating a complication in the bone repair process. Documentation should clearly state the fracture site and the ongoing nature of the healing issue.

• Ensure documentation specifies "delayed healing" or "nonunion" for the skull vault fracture; otherwise, a routine subsequent encounter code would be more appropriate.
• This code requires a seventh character of "G" for subsequent encounter with delayed healing. Other seventh characters exist for initial encounter or subsequent encounter with routine healing.
• Always sequence this code as the primary diagnosis if the delayed healing is the reason for the encounter, followed by any associated complications.