Nondisp fx of unsp tibial spine, subs for clos fx w malunion

This code signifies a follow-up visit for a patient who previously sustained a fracture of an unspecified tibial spine, where the bone fragments were not displaced at the time of the initial injury. During the healing process, the fracture has united in an imperfect or misaligned position, but the skin over the fracture site remains intact.

This code is appropriate for encounters where a patient is being evaluated or treated for complications arising from a malunion of a previously treated, nondisplaced, closed tibial spine fracture. This includes scenarios such as physical therapy for functional limitations due to the malunion, or follow-up imaging to assess the extent of the malunion.

• Ensure documentation clearly states "malunion" and specifies a "subsequent encounter" for the fracture.
• Verify the original fracture was nondisplaced and closed; if not, a different code may be more appropriate.
• Always sequence this code after any primary reason for the encounter, if applicable.