Displ transverse fx shaft of unsp tibia, 7thF

This code describes a fracture of the mid-portion of the tibia that has shifted out of alignment and has broken through the skin, exposing bone or significant soft tissue damage. This specific code is used when the patient is receiving follow-up care for this severe open fracture, and the healing process is progressing as expected.

Apply this code for subsequent encounters when a patient with a previously diagnosed displaced transverse open fracture (Type IIIA, IIIB, or IIIC) of the tibial shaft is undergoing routine follow-up treatment, such as cast changes, wound checks, or physical therapy, and the fracture is healing without complications. This code is appropriate after the initial treatment of the acute injury.

• Ensure documentation specifies a displaced transverse fracture of the tibial shaft and an open fracture type IIIA, IIIB, or IIIC.
• Confirm the encounter is for subsequent care and that routine healing is indicated in the medical record.
• Do not use this code for initial treatment of the fracture or if complications such as delayed healing, nonunion, or malunion are present.