Unsp physeal fracture of upper end of unsp tibia, init

This code describes a fracture involving the growth plate (physis) at the top portion of the shin bone (tibia) in an unspecified location. The fracture type is not further specified, and it is the first time the patient is receiving treatment for this injury, which is a closed fracture (skin intact).

This code is appropriate for initial encounters when a pediatric patient presents with a physeal fracture of the proximal tibia, but the specific type of Salter-Harris classification (e.g., Type I, II, III, IV, V) is not documented or determined. It is also used when the laterality (left or right) of the tibia is not specified in the medical record.

• Only use this code for the initial treatment of a closed fracture. Subsequent encounters will require a different seventh character.
• Avoid this code if the specific Salter-Harris type or laterality of the tibia is documented; instead, choose a more specific code.
• Query the provider for more specific documentation regarding the Salter-Harris classification and laterality if available.