Nondisp spiral fx shaft of unsp tibia, 7thN

This code describes a specific type of tibial shaft fracture that is spiral in nature and has not been displaced. It indicates that the fracture is an open fracture of type IIIA, IIIB, or IIIC, and the patient is in a subsequent encounter for treatment of a nonunion. The unspecified tibia indicates that the laterality is not documented.

Use this code for follow-up encounters when a patient presents with a previously diagnosed open spiral fracture of the tibial shaft (types IIIA, IIIB, or IIIC) that has failed to heal properly, resulting in a nonunion. This code is appropriate when the fracture is confirmed to be nondisplaced and the specific side of the tibia is not documented in the medical record.

• Ensure documentation clearly specifies "subsequent encounter" and "nonunion" for an open fracture.
• Verify the fracture is explicitly described as "nondisplaced" and "spiral" of the tibial shaft.
• Only use this code when laterality (left or right) of the tibia is not documented; otherwise, a more specific code should be selected.