Colles' fx unsp radius, subs for opn fx type I/2 w malunion

This code signifies a Colles' fracture of the radius, where the specific side (left or right) is not documented. It indicates a subsequent encounter for a fracture that was initially open (Type I or II) and has now healed with a malunion, meaning the bone fragments have united in an unsatisfactory position. This malunion may lead to functional impairment or cosmetic deformity.

Use this code when a patient presents for follow-up care of a previously treated open Colles' fracture (Type I or II) of an unspecified radius, and the documentation clearly indicates the presence of a malunion. This could include visits for assessment of ongoing symptoms, planning for corrective surgery, or management of complications arising from the malunion.

• Ensure documentation explicitly states "malunion" and that the initial fracture was an "open fracture type I or II."
• If the laterality (left or right) of the radius is documented, a more specific code should be used.
• This code is for subsequent encounters; an initial encounter for the fracture would use a different code.