LeFort II fracture, subs encntr for fracture with nonunion

This code signifies a LeFort II fracture of the maxilla that is currently undergoing treatment for a nonunion. A LeFort II fracture involves the nasal bones, medial orbital walls, and maxilla, resulting in a pyramidal shape. Nonunion indicates that the fracture has failed to heal completely after an expected period.

Apply this code when a patient presents for follow-up care, such as cast changes, physical therapy, or medication management, for a previously diagnosed LeFort II fracture that has not united. Documentation should clearly state "LeFort II fracture," "nonunion," and indicate a "subsequent encounter" or ongoing treatment.

• Ensure documentation specifies "nonunion" and not delayed union or malunion, as these have different codes.
• This code requires a seventh character of "K" for subsequent encounter for fracture with nonunion.
• Always sequence this code first when it is the primary reason for the encounter.