Nondisp bimalleol fx r low leg, subs for clos fx w malunion

This code describes a right lower leg fracture involving both the medial and lateral malleoli, where the bone fragments are still in their normal anatomical alignment. The fracture has previously been treated, but the bone is healing incorrectly, resulting in a malunion. This code is used during the ongoing management of this specific complication.

Use this code when a patient presents for follow-up care, evaluation, or treatment of a right bimalleolar fracture that has healed in an unsatisfactory position (malunion), and the fracture was initially treated without surgical intervention to realign the bone fragments. This applies to encounters after the initial treatment phase, where the malunion is the primary focus of the visit.

• Ensure documentation clearly specifies "nondisplaced" and "bimalleolar" for the right lower leg.
• Verify that the encounter is for a "subsequent encounter" and that "malunion" is explicitly documented as the complication.
• Do not use this code for initial treatment, routine follow-up without complications, or nonunion.