Unsp fx upr end r tibia, subs for opn fx type I/2 w nonunion

This code describes a situation where the upper part of the right shin bone (tibia) has an unconfirmed type of fracture, and the patient is receiving follow-up care for an open fracture (where the bone broke through the skin) that is classified as Type I or II. Importantly, the fracture has not healed properly, indicating a nonunion.

This code is appropriate for subsequent encounters when a patient with an initial open fracture of the proximal right tibia (Type I or II) is being treated for a nonunion. This includes situations like ongoing wound care, repeat imaging to assess healing, or preparation for revision surgery due to the nonunion.

• Ensure documentation clearly specifies "nonunion" and an "open fracture type I or II" for the subsequent encounter.
• Verify the laterality is "right" and the fracture location is the "upper end of tibia."
• Do not use for initial encounters or for fractures that are healing normally.