Displ bimalleol fx r low leg, subs for clos fx w malunion

This code signifies a right lower leg fracture involving both the medial and lateral malleoli, where the bone fragments are not properly aligned. The fracture has previously been treated, but healing has occurred in an unsatisfactory position (malunion), and the patient is now presenting for follow-up care or management of this complication.

Use this code for patients presenting for an office visit, imaging, or other treatment related to a previously treated, displaced bimalleolar fracture of the right lower leg that has healed with malunion. This applies to situations where the malunion is being monitored, evaluated for corrective surgery, or managed non-surgically.

• Ensure documentation clearly specifies "right" lower leg and "bimalleolar" fracture.
• Confirm the encounter is for a "subsequent encounter" and that "malunion" is documented as the healing outcome.
• Do not use this code for initial treatment of the fracture or for nonunion.