Sltr-haris Type II physeal fx upper end of unsp fibula, init

This code signifies a Salter-Harris Type II fracture affecting the growth plate at the upper end of the fibula, where the fracture line extends through the physis and into the metaphysis. This specific type of physeal fracture is common in children and adolescents, involving a break in the bone near the joint that includes the growth plate. The "unspecified fibula" indicates that laterality (left or right) is not documented.

Use this code for the initial encounter of a patient presenting with a closed Salter-Harris Type II fracture of the proximal fibular growth plate. This applies when the medical record clearly indicates this specific fracture type and location, and there is no open wound communicating with the fracture site. It is appropriate when the documentation does not specify whether the fracture is on the left or right side.

• Ensure documentation explicitly states "Salter-Harris Type II" and "fibula" (or "proximal fibula") to support this code.
• Verify that the encounter is the "initial encounter" for treatment of the closed fracture.
• If laterality (left or right) is documented, a more specific code should be used.