Nondisp fx of med malleolus of l tibia, 7thQ

This code signifies a healed or healing fracture of the inner ankle bone (medial malleolus) of the left lower leg, which was initially an open fracture (skin broken) of either Type I or II severity. The fracture has healed, but with an imperfect alignment (malunion).

Apply this code when a patient presents for follow-up care of a previously treated open medial malleolus fracture of the left tibia, and imaging or clinical assessment confirms malunion. This code is appropriate for encounters after the initial treatment phase, where the focus is on managing the consequences of the malunion.

• Ensure documentation specifies "left" tibia and "medial malleolus" to support this specific code.
• Verify the initial injury was an "open fracture type I or II" and that "malunion" is clearly documented.
• This code is for "subsequent encounter" and should not be used for initial treatment or active healing without malunion.