Nondisp bimalleol fx unsp low leg, 7thH

This code signifies a fracture involving both the medial and lateral malleoli of an unspecified lower leg, where the bone fragments are still in their normal anatomical alignment. This specific encounter is for an open fracture (meaning the skin was broken) that was initially classified as Type I or II, and is now experiencing a delay in the normal healing process.

This code is appropriate for follow-up encounters where a patient with a previously diagnosed bimalleolar open fracture (Type I or II) of an unspecified lower leg is presenting with evidence of delayed union. This includes situations where the fracture site is not showing expected callus formation or bone bridging within the typical timeframe for healing.

• Ensure documentation clearly specifies "nondisplaced" and "bimalleolar" for the fracture.
• Verify the original fracture was an "open fracture type I or II" and that the current encounter is for "delayed healing."
• Do not use if the fracture is displaced, involves only one malleolus, or is an initial encounter.