Disp fx of lateral malleolus of r fibula, 7thQ

This code describes a right fibula fracture, specifically involving the lateral malleolus, that has healed incorrectly (malunion). The initial injury was an open fracture, classified as Type I or II, meaning there was a break in the skin communicating with the fracture site. This code is used when the patient is seen for follow-up care related to this malunited fracture.

This code is appropriate for documenting a patient encounter where the primary reason for the visit is the management or assessment of a malunited displaced lateral malleolus fracture of the right fibula. This includes scenarios such as evaluating pain, limited range of motion, or deformity resulting from the malunion, or planning for corrective surgery. It is used after the initial treatment phase for the acute fracture has concluded.

• Ensure documentation clearly states "malunion" and specifies the right lateral malleolus.
• Verify the original fracture was an "open fracture type I or II" to justify the "Q" seventh character.
• This code is for subsequent encounters; use an initial encounter code for the acute injury.