Unstbl burst fx fourth lum vertebra, subs for fx w nonunion

This code signifies a severe, unstable fracture of the fourth lumbar vertebra where the vertebral body has been significantly compressed and shattered. The "unstable" nature indicates a high risk of spinal cord or nerve root compromise. Furthermore, the fracture has failed to heal properly, leading to a nonunion, and the patient is presenting for follow-up care related to this ongoing issue.

Use this code for patients who have previously been treated for an unstable burst fracture of the L4 vertebra, but the fracture has not united and they are returning for subsequent management of the nonunion. This applies to encounters for ongoing treatment, evaluation of complications, or planning for further intervention related to the unhealed fracture.

• Ensure documentation clearly states "unstable burst fracture" of L4 and "nonunion" for this specific encounter.
• Verify that this is a subsequent encounter for the fracture, not the initial treatment.
• Do not use this code if the fracture is stable, if it's a different type of fracture, or if it's a different lumbar vertebra.