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

This code signifies a fracture of the upper portion of the tibia (shin bone) that is not specifically classified as another type of fracture, and the patient is presenting for follow-up care. The initial fracture was closed (skin intact), and it has healed in a misaligned or deformed position (malunion).

Use this code when a patient is seen for ongoing management or evaluation of a previously sustained, non-specific closed fracture of the proximal tibia that has resulted in malunion. This applies to subsequent encounters after the initial treatment of the acute fracture.

• Ensure documentation clearly states "malunion" and specifies a "subsequent encounter" for the fracture.
• Confirm the fracture location is the "upper end of the tibia" and is not further specified (e.g., plateau, tuberosity).
• Verify the original fracture was closed; if it was open, a different code would be appropriate.