Sltr-haris Type IV physeal fx unspecified calcaneus, init

This code signifies a severe growth plate fracture in the heel bone (calcaneus) of an immature skeleton, specifically a Salter-Harris Type IV injury. This type of fracture involves both the epiphysis (end of the bone) and metaphysis (shaft of the bone), extending through the physis (growth plate). The "unspecified calcaneus" indicates that the laterality (left or right) of the injury is not documented.

Apply this code for initial encounters when a patient presents with a newly diagnosed Salter-Harris Type IV fracture of the calcaneal growth plate, and the fracture is closed (skin intact). This is appropriate when the medical record does not specify whether the injury is to the left or right calcaneus.

• Ensure the documentation explicitly states "Salter-Harris Type IV" and "calcaneus."
• Confirm the encounter is for the initial treatment of the fracture.
• Only use "unspecified calcaneus" if laterality is truly not documented; otherwise, code to the specific side.