Oth fx shaft of left tibia, subs for clos fx w malunion

This code signifies a fracture of the main part (shaft) of the left shin bone that is currently being treated, but not as the initial injury. It specifically indicates that the fracture has healed in an imperfect or misaligned position (malunion) and is a closed fracture, meaning the skin was not broken.

Use this code for follow-up encounters where a patient is being managed for a left tibial shaft fracture that has healed incorrectly. This applies when the malunion is a known complication and the patient is receiving ongoing care, such as physical therapy, imaging to assess the malunion, or planning for corrective surgery.

• Ensure documentation clearly states "left tibia shaft" and "malunion" for a closed fracture.
• Verify that the encounter is for subsequent care, not the initial treatment of the fracture.
• Distinguish from nonunion (failure to heal) or delayed union (slow healing) as these have different codes.