Unsp fx shaft of r tibia, 7thJ

This code signifies a fracture of the main part of the right shin bone, where the specific type of fracture is not documented. It indicates that the initial injury was an open fracture (meaning the bone broke through the skin) classified as Type IIIA, IIIB, or IIIC, and the patient is now presenting for follow-up care due to delayed healing of that fracture.

Apply this code when a patient with a previously diagnosed open fracture (Type IIIA, IIIB, or IIIC) of the right tibial shaft is seen for ongoing management because the fracture is not healing at the expected rate. This would be used for subsequent encounters after the initial treatment of the acute fracture.

• Ensure documentation clearly states "delayed healing" for this subsequent encounter.
• Verify the initial fracture was an open fracture of the right tibial shaft, classified as Type IIIA, IIIB, or IIIC.
• Do not use for initial encounters or for fractures that are healing normally or with nonunion.