Displ trimalleol fx r low leg, subs for clos fx w malunion

This code signifies a right lower leg fracture involving all three malleoli (medial, lateral, and posterior) that has healed incorrectly, resulting in a malunion. The fracture was displaced at the time of injury, and this code is used during a follow-up visit for the now-closed fracture.

Apply this code when a patient presents for ongoing care or evaluation of a previously treated trimalleolar fracture of the right lower leg that has demonstrably healed in an unsatisfactory alignment. This would include scenarios where the malunion is causing functional impairment or pain, and the fracture is no longer open.

• Ensure documentation clearly specifies "right lower leg" and "trimalleolar" involvement.
• Verify that the fracture is documented as "closed" and that the encounter is for a "subsequent" visit with evidence of "malunion."
• Do not use this code for initial treatment or for non-displaced fractures.