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2025 ICD-10-CM code S72.044F

Nondisplaced fracture of the base of the neck of the right femur, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing.

A secondary code from Chapter 20, External causes of morbidity (V00-Y99), should be used to specify the cause of the initial injury. Also, use an additional code (Z18.-) if there's any retained foreign body.

Medical necessity for the subsequent encounter is established by the need for ongoing monitoring of the fracture healing process, pain management, and potential complications of an open fracture like infection. This typically involves assessment of the fracture site, range of motion, and any signs of infection or delayed healing.

In simple words: This code refers to a follow-up visit for a break at the bottom of the right hip bone's neck. The break, which went through the skin, is healing as expected. It's a specific type of hip fracture, and the "IIIA, IIIB, or IIIC" part tells how serious the initial injury was.

This code describes a nondisplaced fracture at the base of the neck of the right femur. It is a subsequent encounter for an open fracture, classified as type IIIA, IIIB, or IIIC according to the Gustilo classification system, and is currently healing normally. The Gustilo classification system grades the severity of open fractures based on factors like the extent of soft tissue damage, the size of the wound, and the level of contamination.

Example 1: A patient had an open fracture of the base of the right femoral neck classified as Gustilo type IIIB, treated with surgical intervention and is now being seen for a follow-up visit with normal healing progress., A patient initially presented with an open, nondisplaced fracture of the base of their right femoral neck. It was determined to be a IIIA Gustilo open fracture. They are now seen for a follow-up appointment, and the fracture is healing normally., A patient experienced an open fracture of the base of their right femoral neck in a motorcycle accident several weeks ago. It was categorized as a Gustilo type IIIC open fracture. Today's visit is a follow-up appointment, and the physician notes the fracture is healing without complications.

Documentation should include details of the initial injury, the Gustilo classification type (IIIA, IIIB, or IIIC), the treatment provided, and the current healing status of the fracture. Previous encounter notes, imaging reports (X-rays, CT, MRI), and operative reports should support the code selection.

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