Maxillary fracture, unspecified side, init

This code signifies a break in the upper jaw bone (maxilla) where the skin and mucous membranes remain intact, indicating a closed fracture. The specific side of the face affected by the fracture is not documented or is unknown.

Apply this code for a patient presenting with a newly diagnosed maxillary fracture where the medical record does not specify whether it's on the left or right side. Documentation should clearly state a maxillary fracture and confirm it is a closed injury, often seen in initial evaluations following trauma.

• Ensure documentation explicitly states "unspecified side" or lacks laterality for the maxillary fracture.
• Verify the encounter is the "initial encounter" for treatment of the fracture, not a subsequent follow-up.
• Distinguish from open fractures (where skin is broken) and fractures of other facial bones.