Displ spiral fx shaft of l tibia, 7thQ

This code signifies a left tibial shaft fracture, specifically a spiral type, that is no longer in proper alignment and was initially an open fracture (Type I or II). The patient is presenting for follow-up care after initial treatment, and the fracture has healed in a misaligned position. This indicates a complication of the initial fracture healing process.

Use this code for a patient who has previously undergone treatment for an open spiral fracture of the left tibial shaft and is now being seen for issues related to the fracture healing with malunion. This applies to subsequent encounters where the malunion is the primary focus of the visit.

• Ensure documentation clearly specifies "left tibia" and "spiral fracture."
• Verify the initial fracture was documented as an "open fracture type I or II."
• Confirm the encounter is for a "subsequent encounter" and that "malunion" is explicitly stated or clearly implied by the clinical findings.