Oth fx upr end l tibia, subs for opn fx type I/2 w malunion

This code describes a fracture of the upper portion of the left tibia, excluding the condyles or tuberosity, that is currently healing with an unsatisfactory alignment (malunion). The original injury was an open fracture, classified as Type I or II, meaning there was a break in the skin communicating with the fracture site. This code is used for follow-up care after the initial treatment of the fracture.

Use this code for patients presenting for follow-up appointments, physical therapy, or other ongoing care related to a previously treated open Type I or II fracture of the upper left tibia that has healed incorrectly. This typically applies when imaging confirms malunion and the patient is experiencing symptoms or complications related to the improper healing.

• Ensure documentation clearly specifies "malunion" and that the original fracture was an "open Type I or II."
• Verify the laterality is "left" and the fracture location is the "upper end of tibia," excluding specific condylar or tuberosity fractures.
• This is a subsequent encounter code; do not use for initial treatment or active treatment of nonunion.