Fx tib/fib fol insrt ortho implnt/prosth/bone plt, unsp leg

This code signifies a fracture of either the tibia or fibula that occurs after a patient has undergone surgery to implant an orthopedic device, such as a joint prosthesis, bone plate, or other internal fixation. This type of fracture is considered a complication directly related to the presence of the implant. The "unspecified leg" indicates that the laterality (left or right) of the fracture is not documented.

Apply this code when documentation clearly states a fracture of the tibia or fibula has occurred following the insertion of an orthopedic implant. This is typically seen in scenarios where the implant may have contributed to bone weakening or stress, or during revision surgery. Supporting documentation should specify the bone fractured and the presence of a prior implant.

• Ensure the fracture is explicitly stated as occurring after implant insertion, not during the initial procedure.
• If laterality (left or right leg) is specified in the documentation, use a more specific code from the M96.67 subcategory.
• This code is for the fracture itself; additional codes may be needed for the implant complication (e.g., mechanical complication of internal orthopedic prosthetic device).