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

This code signifies a follow-up visit for a patient who previously sustained a fracture to the upper portion of their left tibia, excluding the tibial plateau and tuberosity. The fracture is no longer acute and has healed in an imperfect alignment, known as a malunion, and the skin over the fracture site remains intact.

Apply this code when documenting ongoing care for a closed left proximal tibia fracture (excluding plateau/tuberosity) that has healed with a noticeable deformity or angulation. This is appropriate for patients undergoing rehabilitation, monitoring, or planning for corrective procedures due to the malunion.

• Ensure documentation clearly specifies "malunion" and that the fracture is "closed" and "subsequent."
• Verify the fracture location is the "upper end of tibia" but not specifically the plateau or tuberosity.
• Confirm laterality is "left" to avoid coding errors.