Nondisp trimalleol fx unsp low leg, 7thE

This code describes a fracture involving all three malleoli (medial, lateral, and posterior) of an unspecified lower leg, where the bone fragments remain in their normal anatomical alignment. It specifically indicates an open fracture (skin broken) that was initially classified as Type I or II according to the Gustilo-Anderson classification, and the patient is now in a subsequent phase of care with expected routine healing.

Use this code for follow-up encounters for patients recovering from a trimalleolar fracture of an unknown lower leg, where the initial injury was an open fracture (Type I or II) and the fracture fragments are nondisplaced. This applies when the patient is progressing as expected through the healing process, such as during cast changes, follow-up X-rays, or physical therapy appointments after the initial treatment.

• Ensure documentation specifies "nondisplaced" and "trimalleolar fracture" of an "unspecified lower leg."
• Confirm the initial injury was an "open fracture type I or II" and the current encounter is for "routine healing."
• Do not use for initial encounters or for fractures with delayed healing, nonunion, or malunion.