Malar fracture, unspecified side, 7thD

This code signifies a fracture of the malar bone (cheekbone) where the specific side (left or right) is not documented. The patient is in the healing phase following initial treatment, and the healing process is progressing as expected without complications.

Apply this code for follow-up encounters of a malar fracture when the physician's documentation indicates routine healing and does not specify the affected side. This is appropriate when the patient is seen for cast changes, wound checks, or physical therapy during the healing period. Documentation should clearly state "subsequent encounter" or similar language indicating ongoing care for a previously treated fracture.

• Ensure the documentation explicitly states "subsequent encounter" and "routine healing" for appropriate use of the 7th character "D".
• Avoid using this code if the documentation specifies a particular side (e.g., left or right malar fracture); instead, select the more specific code.
• Do not use for initial treatment of the fracture or for encounters involving delayed healing, nonunion, or malunion.