Maxillary fracture, right side, init

This code signifies a break in the upper jawbone (maxilla) on the right side, sustained recently, where the skin and mucous membranes overlying the fracture remain intact. It indicates the initial treatment or evaluation for this specific injury.

Apply this code for a patient presenting with a newly diagnosed, non-compound fracture of the right maxilla. Documentation should clearly state "maxillary fracture," specify "right side," confirm "closed fracture," and indicate that this is the first time the patient is receiving care for this particular injury.

• Ensure documentation explicitly states "right side" of the maxilla; otherwise, an unspecified laterality code may be more appropriate.
• Verify the fracture is indeed "closed"; open fractures require different coding.
• Confirm this is the initial encounter for the fracture; subsequent care would use a different encounter character.