Displ trimalleol fx r low leg, 7thQ

This code signifies a right lower leg fracture involving all three malleoli (medial, lateral, and posterior) that has healed improperly (malunion). The initial injury was an open fracture, classified as Type I or Type II, meaning there was a break in the skin communicating with the fracture site. This specific code is used during follow-up care after the initial treatment of the fracture.

Use this code for patients presenting for ongoing management of a previously treated displaced trimalleolar fracture of the right lower leg, where the fracture has healed with an unacceptable alignment (malunion). This applies when the original injury was an open fracture of Gustilo-Anderson Type I or II. This code would be appropriate for clinic visits, imaging studies, or discussions regarding corrective surgery for the malunion.

• Always confirm the laterality (right leg) and the specific type of fracture (trimalleolar).
• Verify documentation explicitly states "malunion" and that the original injury was an "open fracture Type I or II."
• Ensure this is a "subsequent encounter" code, meaning the patient is no longer in the initial phase of treatment for the acute fracture.