Pathological fracture, right tibia, subs for fx w malunion

This code signifies a fracture of the right tibia that occurred due to an underlying disease process, rather than trauma. The patient is now in a subsequent phase of care for this fracture, and the bone has healed improperly, resulting in a malunion. This indicates ongoing management of the poorly aligned healed fracture.

This code is appropriate when a patient presents for follow-up care, rehabilitation, or further surgical intervention related to a previously diagnosed pathological fracture of the right tibia that has healed in an anatomically incorrect position. Documentation should clearly state "pathological fracture," specify the right tibia, indicate a malunion, and confirm that this is not the initial treatment encounter.

• Ensure documentation explicitly states "pathological fracture" to differentiate from traumatic fractures.
• Verify the laterality (right tibia) and the encounter type (subsequent encounter for fracture with malunion).
• Always sequence this code after the underlying condition responsible for the pathological fracture, if applicable and still active.