Unsp fx upper end of left tibia, subs for clos fx w nonunion

This code signifies a fracture in the upper portion of the left shin bone, where the specific type of fracture is not documented. It indicates that the patient is receiving ongoing care for this closed fracture, and the bone fragments have failed to heal together properly, resulting in a nonunion.

Apply this code when a patient presents for follow-up treatment of a previously diagnosed, unspecified closed fracture of the proximal left tibia that has not healed. This includes situations where surgical intervention for nonunion is being planned or performed, or when conservative management for the nonunion is ongoing.

• Ensure documentation clearly states "left tibia" and "upper end" or "proximal."
• Verify the encounter is for subsequent care and the fracture is closed with documented nonunion.
• Do not use for initial encounters or if the fracture is healing normally.