Sltr-haris Type IV physl fx low end r tibia, 7thP

This code signifies a specific type of growth plate fracture (Salter-Harris Type IV) affecting the lower end of the right shin bone, where the fracture has healed improperly (malunion). This indicates a previous injury that has not aligned correctly during the healing process, leading to potential functional impairment.

This code is used when a patient presents for follow-up care of a previously diagnosed Salter-Harris Type IV fracture of the distal right tibia, and imaging or clinical assessment confirms that the fracture has healed in a misaligned position. This would apply to encounters for managing the complications of the malunion, such as pain, deformity, or planning for corrective surgery.

• Ensure documentation clearly specifies "right tibia" and "Salter-Harris Type IV" to support this code.
• Verify that "malunion" is explicitly documented, distinguishing it from nonunion or routine follow-up.
• This code indicates a subsequent encounter, so ensure the patient is past the initial active treatment phase for the fracture.