Nondisp spiral fx shaft of r tibia, 7thC

This code describes a break in the shaft of the right shin bone that spirals around the bone, but the bone fragments remain in their normal anatomical position. The fracture is open, meaning the bone has broken through the skin, and is classified as a severe open fracture (Type IIIA, IIIB, or IIIC) according to the Gustilo-Anderson classification. This code is used for the initial treatment of this injury.

This code is appropriate for documenting the initial encounter for a patient presenting with a newly diagnosed, nondisplaced spiral fracture of the diaphysis of the right tibia that has an associated open wound meeting the criteria for Gustilo-Anderson Type IIIA, IIIB, or IIIC. This would include scenarios such as high-energy trauma where bone is exposed or significant soft tissue damage is present.

• Ensure documentation clearly specifies "nondisplaced" and "spiral" fracture of the tibial shaft.
• Verify the open fracture type (IIIA, IIIB, or IIIC) is explicitly stated in the medical record.
• This "C" encounter code is only for the initial treatment; subsequent care will require different encounter codes.