Oth fx upper end of left tibia, subs for clos fx w nonunion

This code signifies a fracture of the upper portion of the left tibia, excluding specific condylar or tuberosity fractures, that has failed to heal properly after an initial treatment. The fracture is currently closed, meaning the skin remains intact over the injury site. This code is used for follow-up care related to this persistent nonunion.

This code is appropriate when a patient presents for ongoing management of a previously treated, but unhealed, closed fracture of the proximal left tibia. This includes scenarios such as follow-up appointments, imaging studies to assess nonunion progression, or surgical interventions aimed at promoting healing of the nonunion. It specifically applies to subsequent encounters after the initial treatment of the fracture.

• Ensure documentation clearly states "nonunion" and specifies the left tibia and its upper end.
• Verify that the encounter is for follow-up care of the nonunion, not the initial injury or acute treatment.
• Confirm the fracture is documented as "closed" at the time of this encounter.