Oth fx lower end of left tibia, subs for clos fx w malunion

This code indicates a fracture of the lower portion of the left shin bone (tibia) that is currently healing, but has done so in an unsatisfactory position (malunion). The fracture itself was a closed fracture, meaning the skin was not broken at the time of injury.

Use this code when a patient presents for follow-up care, such as cast changes, physical therapy, or imaging, for a previously diagnosed closed fracture of the distal left tibia that has healed incorrectly. This code is appropriate when the malunion is documented and the patient is still under active treatment for the fracture's sequelae.

• Ensure documentation specifies "left" tibia and "lower end" or "distal" to differentiate from other tibial fracture locations.
• Verify the encounter is for a "subsequent" visit and that "malunion" is explicitly documented as the current healing status.
• Do not use this code for initial treatment of the fracture or for nonunion, which is a separate complication.