Unsp fx upper end of l tibia, subs for clos fx w delay heal

This code signifies a fracture of the upper portion of the left tibia, where the specific type of fracture (e.g., spiral, transverse) is not documented. It indicates that the patient is in a follow-up period for a fracture that was initially closed (skin intact) but is now experiencing delayed healing.

This code is appropriate for use in subsequent encounters when a patient with a previously diagnosed, unspecified closed fracture of the proximal left tibia is not healing at the expected rate. This would typically be documented by the physician as delayed union or delayed healing of the fracture. It should be used after the initial treatment phase and when the fracture site is still being managed.

• Ensure documentation explicitly states "delayed healing" or "delayed union" for a closed fracture.
• Verify the fracture location is the "upper end" or "proximal" tibia and laterality is "left."
• Do not use for nonunion or malunion; separate codes exist for those complications.