Nondisp pilon fx unsp tibia, 7thE

This code describes a pilon fracture of the tibia, which is a break at the bottom end of the shin bone, near the ankle joint. In this specific case, the bone fragments are still in their normal alignment (nondisplaced), and the fracture is open (meaning the bone broke through the skin) classified as Type I or II. This code is used when the patient is receiving follow-up care for the healing of this injury.

Apply this code for patients presenting for routine follow-up appointments, cast changes, or wound checks after initial treatment of a nondisplaced open pilon fracture of an unspecified tibia (Type I or II). This indicates that the fracture is progressing as expected through the healing process.

• Ensure documentation specifies "nondisplaced" and "open fracture type I or II" for accurate code assignment.
• Confirm the encounter is for subsequent care and routine healing, not initial treatment or delayed/nonunion.
• Always code the specific laterality (left or right) if documented; "unspecified" should only be used when laterality is not recorded.