Torus fx upper end of unsp tibia, subs for fx w malunion

This code signifies a torus, or buckle, fracture affecting the upper portion of the tibia, where the bone has healed in an abnormal alignment. This particular code is used when the patient is receiving follow-up care for this malunited fracture, indicating that the initial treatment has concluded and the focus is now on managing the resulting deformity.

Apply this code when a patient presents for ongoing treatment, rehabilitation, or evaluation of a previously sustained torus fracture of the proximal tibia that has healed incorrectly. This includes scenarios where the malunion is causing functional impairment, pain, or requires further intervention such as corrective osteotomy planning.

• Ensure documentation clearly states "malunion" and specifies the "subsequent encounter" for this specific fracture type.
• Verify the fracture location is the "upper end of the tibia" and the fracture type is a "torus fracture."
• Do not use this code for initial treatment or for nonunion; a different code would be appropriate in those instances.