Malar fracture, unspecified side, init

This code signifies a fracture of the malar bone (zygoma) where the specific side (left or right) is not documented. It indicates that the skin and underlying tissue remain intact over the fracture site, and this is the first time the patient is receiving active treatment for this injury.

Apply this code when documentation confirms a malar fracture but does not specify laterality, and the fracture is explicitly stated as closed. This is appropriate for the initial phase of treatment, such as emergency department visits, initial consultations, or hospital admissions for the acute injury.

• Ensure documentation clearly states "closed fracture" and lacks laterality for the malar bone.
• For subsequent encounters for the same fracture, use the appropriate seventh character (D, G, K, P, S).
• If laterality is specified, use a more specific code (e.g., S02.401A for right, S02.402A for left).