2025 ICD-10-CM code M84.38XP
Stress fracture, other site, subsequent encounter for fracture with malunion.
Medical necessity for this code is established by the presence of a documented stress fracture that has progressed to malunion, requiring ongoing care. The documentation should support the need for continued treatment and the impact of the malunion on the patient's function.
A stress fracture may result in swelling, tenderness, and sometimes bruising with pain aggravated by routine activities and alleviated with rest. Providers diagnose the condition on the basis of the patient’s history, particularly regarding work and recreational activities; physical examination; laboratory examination of the blood for calcium and vitamin D; and imaging techniques such as X–ray, magnetic resonance imaging, and bone scan. Treatment options include lifestyle modification, rest, splint or cast for immobilization, special shoes that support the arch and ankles, administration of medications such as analgesics and nonsteroidal antiinflammatory drugs to relieve pain, and surgical repair for severe cases.
- Diseases of the musculoskeletal system and connective tissue (M00-M99)
- Disorders of bone density and structure (M80-M85)Osteopathies and chondropathies (M80-M94)
In simple words: A stress fracture is a small crack in a bone, often caused by overuse or repeated impact.It's common in athletes and military recruits. This specific code is used when someone is being seen for a stress fracture that hasn't healed properly, in a place not covered by a more specific code.
Stress fracture, also called a fatigue fracture, march fracture, or hairline fracture, of a site not represented by another code refers to an incomplete break in the bone due to overuse or repeated injury such as in high impact sports or stress or trauma associated with prolonged marching. This code applies to a subsequent encounter for malunion, incomplete uniting of fracture fragments or union in a faulty position of for a stress fracture not represented by another code.
Example 1: A runner experiences persistent pain in their foot after increasing their training mileage. Initial X-rays were negative, but an MRI reveals a stress fracture in the navicular bone.Several weeks later, the patient is still experiencing pain and follow-up imaging shows the fracture has not healed properly (malunion). The provider continues the treatment plan and uses M84.38XP to document the subsequent encounter., A basketball player experiences pain in their shin.They are diagnosed with a tibial stress fracture and advised to rest and limit activity.After 6 weeks, imaging reveals the fracture is healing, but in a slightly misaligned position, leading to discomfort.The code M84.38XP is used for this follow-up visit addressing the malunion., A military recruit experiences pain in their hip after intense basic training. They are diagnosed with an ischial stress fracture.After several weeks of treatment, the pain persists. Further examination reveals the fracture has not united correctly, and M84.38XP is applied since the ischium is a site not specifically covered by other stress fracture codes within the M84.3 range.
Documentation should include details of the initial fracture diagnosis, treatment plan, subsequent imaging results showing malunion, ongoing symptoms, and the continued or revised treatment plan.The location of the fracture should be clearly specified, as this code is for sites other than those with specific stress fracture codes.
- Specialties:Orthopedics, Sports medicine, Physical medicine and rehabilitation, Primary care
- Place of Service:Office, Outpatient Hospital, Military Treatment Facility