Oth fx upr end r tibia, 7thN

This code signifies a complex fracture of the upper part of the right shin bone (tibia) that has not healed properly (nonunion). Specifically, it indicates an open fracture where the bone broke through the skin, classified as a severe type (IIIA, IIIB, or IIIC), and the patient is receiving ongoing treatment for this unhealed break.

Use this code for follow-up encounters when a patient is being managed for a previously diagnosed open fracture of the proximal right tibia (types IIIA, IIIB, or IIIC) that has failed to unite. This includes situations where the patient is undergoing further surgical intervention, cast changes, or other treatments specifically addressing the nonunion.

• Requires a seventh character of "N" for subsequent encounter with nonunion.
• Ensure documentation clearly specifies "open fracture" and the Gustilo-Anderson classification (IIIA, IIIB, or IIIC).
• Confirm the fracture is of the "upper end" of the tibia and on the "right" side.