Unsp physl fx upper end unsp tibia, subs for fx w nonunion

This code signifies a fracture of the growth plate at the top of the shin bone, where the specific location within the tibia is not documented. The patient is in a later stage of care for this injury, and the fracture has failed to heal properly, indicating a nonunion.

Apply this code for follow-up encounters where a patient is being treated for an unhealed physeal fracture of the proximal tibia, and the medical record lacks specificity regarding the exact site of the fracture. This is appropriate when the physician explicitly documents "nonunion" as a complication of the fracture.

• Ensure documentation clearly states "nonunion" and that the encounter is for follow-up care of the fracture.
• Avoid using this code if a more specific location of the physeal fracture (e.g., medial, lateral) is documented.
• Verify that the encounter is not for initial treatment or routine healing, but specifically for the management of the nonunion.