Fracture of ramus of mandible, unspecified side, 7thB

This code signifies a break in the ascending or horizontal portion of the lower jawbone, where the fracture has created an open wound, exposing bone to the external environment. This specific code is used for the initial treatment phase of such an injury when the side of the mandible affected is not specified in the documentation.

Apply this code for a patient presenting with a newly diagnosed open fracture of the mandibular ramus, requiring active treatment. Documentation must clearly indicate an open fracture and specify the initial encounter for care, but lack laterality. Supporting documentation includes emergency department notes, operative reports, and imaging reports confirming the fracture type.

• Ensure documentation explicitly states "open fracture" and "initial encounter" for this specific injury.
• If laterality (left or right) is documented, a more specific code from the S02.64- series should be chosen.
• Always sequence this code as the primary diagnosis when it is the reason for the encounter, followed by any associated external cause codes.