Fx r shoulder girdle, part unsp, subs for fx w malunion

This code signifies a previously sustained fracture of an unspecified part of the right shoulder girdle (e.g., clavicle, scapula, or humerus head) that is now healing improperly, resulting in a malunion. The patient is presenting for ongoing care related to this complication.

Use this code when documenting follow-up care for a patient whose right shoulder girdle fracture has healed in an anatomically incorrect or deformed position. This applies to encounters where the malunion itself is the focus of treatment or evaluation, such as for pain management, functional assessment, or planning for corrective surgery.

• Ensure documentation clearly specifies "right" shoulder girdle and "malunion" for accurate code assignment.
• This code is for subsequent encounters; an initial encounter for the original fracture would use a different seventh character.
• Always review the medical record for laterality and the specific type of healing complication (e.g., nonunion vs. malunion).