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

This code describes a fracture involving all three malleoli (medial, lateral, and posterior) of the right ankle that has not been displaced. The patient is in a subsequent phase of care, and the fracture is closed, but healing has resulted in an imperfect alignment of the bone fragments (malunion).

This code is used when a patient presents for follow-up care, rehabilitation, or further treatment of a right trimalleolar fracture that has healed incorrectly. It specifically applies when the initial injury was closed and the fracture fragments were not displaced, but the subsequent healing process has led to a malunion.

• Ensure documentation clearly states "right lower leg" and "trimalleolar fracture" with "nondisplaced" and "closed."
• Verify the encounter is "subsequent" and specifically addresses the malunion of the fracture.
• Do not use for initial encounters or for fractures that are healing normally or with nonunion.