Nondisplaced trimalleolar fracture of left lower leg, init

This code signifies a fracture involving all three malleoli (medial, lateral, and posterior) of the left ankle, where the bone fragments remain in their normal anatomical alignment. It specifically indicates that this is the first time the patient is receiving active treatment for this particular closed fracture.

Apply this code for initial encounters when documentation confirms a trimalleolar fracture of the left lower leg without displacement, and the skin over the fracture site is intact. This is appropriate for the initial evaluation, stabilization, and treatment planning phase.

• Ensure documentation explicitly states "nondisplaced" and "trimalleolar" for the left lower leg.
• Verify that the encounter is the initial treatment for this specific fracture, not a follow-up.
• Confirm the fracture is closed; open fractures require different coding.