Sltr-haris Type III physeal fx upper end of unsp tibia, init

This code signifies a specific growth plate fracture affecting the upper part of the shin bone (tibia) in a pediatric patient. It's a Salter-Harris Type III injury, meaning the fracture extends through the growth plate and into the epiphysis, but does not involve the metaphysis. This particular instance refers to an unspecified side and is the initial treatment for a fracture where the skin remains intact.

Use this code when documenting the initial encounter for a closed Salter-Harris Type III fracture of the proximal tibia in a child or adolescent. This would typically be seen following trauma to the knee or lower leg, such as from sports injuries or falls. It's appropriate when the specific left or right tibia is not documented.

• Ensure the documentation clearly specifies "Salter-Harris Type III" and "physeal fracture of the upper end of the tibia."
• Verify that this is the initial encounter for treatment and that the fracture is closed.
• Only use this code when the laterality (left or right) of the tibia is not specified in the medical record.