Nondisp spiral fx shaft of unsp tibia, 7thP

This code signifies a follow-up encounter for a patient with a nondisplaced spiral fracture of the tibial shaft, where the fracture is now healing with malunion. Malunion indicates that the bone has healed, but in an anatomically incorrect or misaligned position. This specific code applies to a closed fracture, meaning the skin was not broken.

Use this code for patients presenting for follow-up care of a previously diagnosed tibial shaft spiral fracture that has healed with malunion. This would be appropriate for clinic visits, imaging studies, or other encounters where the physician is assessing the status of the malunion and planning further management. It is not for initial treatment of the fracture or for nonunion.

• Ensure documentation clearly states "malunion" and not "nonunion" (which has different codes).
• Verify the fracture is specifically of the "shaft" and is "spiral" in nature.
• Confirm this is a "subsequent encounter" for a "closed fracture."