Displ bimalleol fx r low leg, 7thN

This code describes a complex fracture involving both the medial and lateral malleoli of the right ankle, where the bone fragments are not in their anatomical alignment. It specifically indicates an open fracture, meaning the skin and soft tissues were significantly compromised, and the fracture has failed to heal properly after an initial treatment. This nonunion suggests a persistent gap or fibrous tissue formation at the fracture site.

Use this code for a patient presenting for follow-up care, such as cast changes, wound management, or evaluation for further surgical intervention, for a previously diagnosed displaced bimalleolar open fracture of the right lower leg. This code is appropriate when the fracture has been classified as Type IIIA, IIIB, or IIIC according to the Gustilo-Anderson classification system, and nonunion has been confirmed.

• Always confirm the laterality (right) and the specific fracture type (bimalleolar, displaced, open Type IIIA/B/C) from the physician's documentation.
• Ensure the encounter is for subsequent care related to the nonunion, not the initial treatment of the acute fracture.
• Verify documentation explicitly states "nonunion" to support the use of the 7th character 'N'.