Nondisp fx of med malleolus of l tibia, 7thC

This code signifies a break in the inner ankle bone (medial malleolus) of the left lower leg bone (tibia) that has not shifted out of its normal alignment. It specifically indicates that the fracture is an open fracture, meaning the skin and soft tissue have been significantly damaged, exposing the bone, and is classified as a severe open fracture type IIIA, IIIB, or IIIC. This code is used for the initial treatment of such an injury.

Use this code when documenting the initial encounter for a patient presenting with a nondisplaced fracture of the left medial malleolus where the bone has broken through the skin, and the wound is extensive, contaminated, or involves significant soft tissue loss, consistent with Gustilo-Anderson open fracture types IIIA, IIIB, or IIIC. This applies to the first time the patient is seen for definitive treatment of this specific injury.

• Ensure documentation clearly specifies "nondisplaced" and identifies the "left medial malleolus" of the tibia.
• Verify that the physician's notes explicitly state the fracture is "open" and classify it as type IIIA, IIIB, or IIIC.
• This code is only for the "initial encounter"; subsequent care for the same injury will require a different seventh character.