Displaced pilon fx right tibia, subs for clos fx w malunion

This code signifies a follow-up encounter for a right lower leg injury involving a pilon fracture, which affects the weight-bearing surface of the tibia at the ankle joint. The fracture is displaced, meaning the bone fragments are not properly aligned, and has healed incorrectly, resulting in a malunion. This indicates a previous closed fracture that has now consolidated in an abnormal position.

This code is appropriate when a patient presents for ongoing management or evaluation of a previously treated closed pilon fracture of the right tibia that has healed with malunion. This could include assessment of pain, functional limitations, or consideration of corrective surgery for the malunited fracture. It is used for subsequent visits after the initial treatment of the fracture.

• Ensure documentation clearly states "malunion" and specifies the right tibia.
• Verify that the encounter is for follow-up care, not the initial treatment of the fracture.
• Confirm the fracture was originally a "closed" fracture.