Nondisp pilon fx l tibia, 7thH

This code describes a pilon fracture, which is a break at the bottom of the shin bone (tibia) near the ankle joint, that has not shifted out of alignment. It specifically indicates that the fracture was initially open (meaning the skin was broken) and is now in a phase of delayed healing, where the bone is taking longer than expected to mend.

This code is used for follow-up encounters when a patient with a previously diagnosed and treated open pilon fracture of the left tibia (Type I or II) is experiencing delayed union. This would apply during subsequent office visits or hospital stays focused on managing the slow healing process, such as for wound care, imaging to assess healing progress, or discussions about further interventions.

• Ensure documentation clearly specifies "nondisplaced" and "left tibia" for the pilon fracture.
• Verify the initial fracture was documented as an "open fracture type I or II" and that the current encounter addresses "delayed healing."
• This code requires an external cause code (e.g., W00-Y38) to describe the circumstances of the injury.