Oth fx shaft of unsp tibia, subs for clos fx w nonunion

This code signifies a fracture of the main part (shaft) of the tibia, where the specific side (left or right) is not documented. The fracture is not healing properly (nonunion) and the patient is presenting for follow-up care or treatment of this previously closed injury.

Apply this code when a patient returns for management of a tibial shaft fracture that has failed to unite, and the initial injury was a closed fracture. This is appropriate for subsequent visits related to the nonunion, such as for casting, surgical planning, or monitoring of the non-healing bone.

• Requires an additional code for the specific type of nonunion (e.g., M84.48XA for nonunion of fracture, lower leg).
• Ensure documentation clearly states "nonunion" and that the initial fracture was "closed."
• Do not use for initial encounters or for open fractures.