Unsp trochan fx r femur, subs for opn fx type I/2 w malunion

This code describes a right femur fracture involving the trochanteric region, where the specific type of trochanteric fracture is not documented. It indicates that the patient is receiving follow-up care for an open fracture (Gustilo type I or II) that has healed in a misaligned or deformed position. This malunion may be causing functional impairment or pain.

Use this code for a patient presenting for ongoing management of a previously treated open trochanteric fracture of the right femur that has resulted in malunion. This applies to encounters for physical therapy, follow-up imaging, or surgical planning to address the malunion, provided the original fracture was an open type I or II.

• Ensure documentation specifies "right femur" and "trochanteric fracture" without further detail on the fracture type (e.g., intertrochanteric, subtrochanteric).
• Verify that the encounter is for subsequent care of a malunion, and the original fracture was explicitly documented as an open type I or II.
• Do not use for initial treatment of the fracture or for nonunion; specific codes exist for those scenarios.