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

This code signifies a Salter-Harris Type IV fracture affecting the growth plate at the top of the tibia, where the fracture line extends through the epiphysis, growth plate, and metaphysis. This specific code is used when the laterality of the tibia is not documented and it represents the initial treatment for a fracture that has not broken through the skin.

Use this code for a pediatric patient presenting with an acute, closed Salter-Harris Type IV fracture of the proximal tibia, when the medical record does not specify whether it's the left or right leg. This code is appropriate for the initial encounter for treatment, such as casting or surgical repair.

• Ensure documentation clearly states "Salter-Harris Type IV" and "proximal tibia."
• Only use this code for the initial encounter; subsequent encounters will require different seventh characters.
• Confirm the fracture is closed; open fractures have distinct coding.