Nondisp spiral fx shaft of r tibia, 7thM

This code describes a right tibia shaft fracture that is spiral in nature, meaning the fracture line twists around the bone, and the bone fragments remain in their normal anatomical alignment. This specific encounter is for an open fracture (where the skin is broken) of either Type I or II, and the fracture has failed to heal properly (nonunion).

This code is appropriate for documentation of follow-up care for a patient with a previously diagnosed nondisplaced spiral fracture of the right tibial shaft. The key indicators for this code are the presence of an open fracture (Type I or II) and the complication of nonunion, indicating the bone is not mending as expected. This would be used for subsequent visits after the initial treatment.

• Ensure documentation clearly specifies "nondisplaced" and "spiral" fracture of the right tibia shaft.
• Verify the open fracture type (I or II) is explicitly stated or clearly inferable from the clinical notes.
• Confirm the encounter is for ongoing management of a nonunion, not an initial injury or routine healing.