Nondisp bimalleol fx r low leg, 7thQ

This code signifies a previously treated fracture involving both the medial and lateral malleoli of the right ankle, which was initially an open fracture (Type I or II) and has now healed in an imperfect alignment. The fracture itself is currently nondisplaced, indicating the bone fragments are in their anatomical position relative to each other, but the overall healing has resulted in a malunion.

This code is used when a patient presents for follow-up care of a right bimalleolar fracture that was initially open, and imaging or clinical assessment confirms that the fracture has healed with a malunion. This would typically be documented by an orthopedic surgeon during a subsequent encounter after the initial treatment phase.

• Ensure documentation clearly specifies "right lower leg" and "bimalleolar" involvement.
• Verify the original fracture was an "open fracture type I or II" and that "malunion" is explicitly stated or clearly implied by the clinical findings.
• Confirm this is a "subsequent encounter" for ongoing care related to the malunion, not the initial treatment or a new injury.