Nondisp trimalleol fx r low leg, subs for clos fx w nonunion

This code describes a fracture involving all three malleoli (medial, lateral, and posterior) of the right ankle, which has not shifted from its anatomical position. It specifically indicates that the patient is in a subsequent phase of care, and the fracture has failed to heal properly, remaining ununited.

Use this code for follow-up encounters where a patient with a previously diagnosed nondisplaced trimalleolar fracture of the right lower leg is being treated for a nonunion. This applies when the fracture site is still closed (skin intact) and the primary focus of the visit is the management of the unhealed fracture.

• Ensure documentation clearly states "nondisplaced," "trimalleolar," "right lower leg," "subsequent encounter," and "nonunion."
• Do not use this code for initial treatment, malunion, or open fractures.
• Verify laterality (right) is explicitly documented to avoid coding errors.