Nondisp fx of med malleolus of unsp tibia, 7thQ

This code signifies a previously treated, non-displaced fracture of the inner ankle bone of an unspecified lower leg, which is now experiencing a complication where the bone has healed in an imperfect alignment. The original injury was an open fracture, meaning the skin was broken, and was classified as type I or II based on the severity of the soft tissue damage.

Use this code for follow-up encounters with a patient who sustained an open type I or II medial malleolus fracture, and subsequent imaging or clinical assessment reveals that the bone has healed in a misaligned position. This code is appropriate when the patient is receiving ongoing care for the malunion, such as physical therapy, further diagnostic workup, or consideration for corrective surgery.

• Ensure documentation clearly states "malunion" and specifies the "medial malleolus" and "nondisplaced" nature of the fracture.
• Verify the original fracture was an "open fracture type I or II" to justify the seventh character 'Q'.
• This code is for subsequent encounters; an initial encounter for the malunion would use a different seventh character.