Nondisp fx of med malleolus of unsp tibia, 7thE

This code describes a fracture of the inner ankle bone (medial malleolus) that has not shifted out of alignment, and the skin over the fracture was broken (open fracture type I or II). It is used when the patient is receiving follow-up care for this injury and the healing process is progressing normally.

This code is appropriate for documenting subsequent visits for a patient recovering from a nondisplaced open medial malleolus fracture (Gustilo-Anderson Type I or II) where the wound is clean and healing without complications. It would be used during routine cast changes, follow-up X-rays, or physical therapy sessions during the initial healing phase.

• Ensure documentation specifies "nondisplaced" and "open fracture type I or II" for accurate code selection.
• Confirm the encounter is for subsequent care and not the initial treatment of the fracture.
• Verify that healing is routine; if complications arise, a different "subsequent encounter" code with a different healing status would be necessary.