Stable burst fracture of unsp lumbar vertebra, init

This diagnosis describes a vertebral body fracture in the lumbar spine that has maintained its structural integrity, meaning it is not unstable or at risk of further collapse. The specific lumbar vertebra involved is not documented. This is the first time the patient is receiving care for this injury, and there is no open wound communicating with the fracture site.

Apply this code for a patient presenting with a newly diagnosed, non-displaced or minimally displaced burst fracture of an unspecified lumbar vertebra. This is appropriate when the physician explicitly states the fracture is stable and the encounter is for the initial treatment or evaluation of the injury. Use when the medical record does not specify which particular lumbar vertebra (e.g., L1, L2) is affected.

• Ensure documentation explicitly states "stable burst fracture" and "unspecified lumbar vertebra."
• Confirm this is the initial encounter for the fracture; subsequent encounters will require a different seventh character.
• Do not use if the documentation specifies a particular lumbar vertebra (e.g., L3); instead, select a more specific code.