Unsp fx shaft of r tibia, 7thQ

This code signifies a previously sustained, unspecified fracture of the shaft of the right tibia that was initially an open fracture (Type I or II) and has subsequently healed in a misaligned or deformed position. The patient is currently receiving active treatment for this malunion.

Apply this code when documenting ongoing care for a patient whose right tibial shaft fracture, originally open, has healed improperly. This includes scenarios where the malunion is being addressed through surgical intervention, physical therapy, or other treatments aimed at correcting the deformity.

• Ensure documentation clearly specifies "malunion" and the "subsequent encounter" for treatment.
• Verify the original fracture was an open fracture, Type I or II, as this impacts the seventh character.
• Do not use for nonunion (failure to heal) or routine follow-up without active treatment for the malunion.