Oth fracture of right lower leg, subs for clos fx w malunion

This code signifies a healed fracture of the right lower leg (tibia, fibula, or ankle, excluding specific malleolar or shaft fractures) that has united in an anatomically incorrect or deformed position. This malunion is being addressed during a follow-up visit after the initial treatment of the closed fracture.

Use this code for patients presenting for evaluation or management of a right lower leg fracture that has healed with a noticeable deformity or angulation, and the fracture was initially closed. This applies to subsequent encounters where the malunion is the primary focus of the visit, such as for assessment of function, pain, or planning for corrective surgery.

• Ensure documentation clearly states "malunion" and specifies the right lower leg.
• Verify the fracture was initially closed; if open, a different code would be appropriate.
• This code is for subsequent encounters; use an initial encounter code for the initial treatment of the malunion if it's a new diagnosis.