Unsp fx upr end l tibia, subs for opn fx type I/2 w malunion

This code signifies a fracture of the upper part of the left shin bone, where the specific type of fracture is not documented. It indicates that the patient is receiving follow-up care for a previously sustained open fracture, specifically one classified as Type I or II, and that the bone fragments have healed in an abnormal position (malunion).

Use this code for subsequent encounters when a patient presents with complications from an open fracture (Type I or II) of the proximal left tibia, and the fracture has healed with malunion. This applies when the initial fracture type was not specified beyond its location and open nature. This code is appropriate for ongoing management of the malunion, such as planning for corrective surgery or monitoring non-operative treatment.

• Ensure documentation clearly states "left tibia," "upper end," and "malunion" in the context of a "subsequent encounter" for an "open fracture type I or II."
• Do not use for initial encounters or for closed fractures.
• Verify the open fracture type (I or II) was documented in the initial injury or subsequent records to support this specific code.