Unsp trochan fx unsp femur, subs for clos fx w malunion

This code signifies a follow-up encounter for a closed fracture of the trochanteric region of the femur, where the specific trochanter (greater or lesser) is not documented. The fracture has healed in an unsatisfactory position, resulting in a malunion. This indicates a previous injury that is now being managed for its long-term complication.

Apply this code when a patient presents for ongoing care or evaluation of a previously sustained, unspecifed trochanteric femoral fracture that has healed incorrectly. This typically occurs after the initial healing phase, when the malunion is identified and is the focus of the current encounter. Examples include follow-up appointments for pain, functional limitations, or planning for corrective surgery related to the malunion.

• Ensure documentation clearly states "malunion" and that the encounter is for a "subsequent" visit.
• Confirm the fracture was "closed" and the specific trochanter is not specified in the medical record.
• Do not use for initial treatment of the fracture or for nonunion; separate codes exist for those scenarios.