Displ pilon fx r tibia, subs for opn fx type I/2 w malunion

This code signifies a pilon fracture of the right tibia that has healed improperly, resulting in malunion. The initial injury was an open fracture, classified as type I or II, meaning there was a break in the skin with minimal to moderate soft tissue damage. This specific code is used during follow-up care for this previously treated fracture.

Apply this code when a patient presents for ongoing treatment or evaluation of a right tibial pilon fracture that has demonstrably healed in an anatomically incorrect position. This would typically occur during subsequent visits after the initial treatment of an open type I or II fracture, where imaging confirms malunion. It indicates that the patient is still under active care for the complications of the fracture.

• Ensure documentation clearly states "malunion" and specifies the right tibia.
• Verify the original fracture was an "open fracture type I or II" as this is a specific inclusion criterion.
• This "Q" seventh character indicates a subsequent encounter, meaning the patient is receiving routine follow-up care during the healing or recovery phase, or for complications like malunion.