Unsp fx l low leg, subs for opn fx type 3A/B/C w delay heal

Unspecified fracture of left lower leg, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

AIClinical Context

Clinical Description

This code signifies an unspecified fracture of the left lower leg that is currently in a delayed healing phase. The fracture was initially an open fracture, classified as type IIIA, IIIB, or IIIC, indicating significant soft tissue damage and contamination.

When to Use

This code is appropriate for follow-up encounters where a patient with a previously diagnosed open lower leg fracture (type IIIA, IIIB, or IIIC) is experiencing delayed union or nonunion. It should be used when the specific bone fractured (e.g., tibia, fibula) is not documented.

Coding Tips

Always confirm the laterality (left) and the specific type of open fracture (IIIA, IIIB, or IIIC) from the medical record.
Ensure documentation clearly indicates "delayed healing" or a similar term to justify the "J" seventh character.
Pair this code with external cause codes (e.g., V00-Y99) and codes for any associated complications, if applicable.

AI-generated reference. Verify against official guidelines.

Crosswalks

V54.16ApproxICD-9

Same Category

S82Fracture of lower leg, including ankle S82.0Fracture of patella S82.00Unspecified fracture of patella S82.001Unspecified fracture of right patella S82.001A