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

This code signifies a growth plate fracture at the top of the shin bone (tibia) where the specific location or type of fracture is not documented. It indicates that the patient is being seen for follow-up care of this fracture, and the bone has healed in an incorrect or deformed position.

Use this code for a patient presenting for ongoing management of a previously diagnosed, non-specific proximal tibial physeal fracture that has healed with malunion. This would apply when the initial encounter for the fracture has passed, and the current visit addresses complications related to the improper healing.

• Ensure documentation clearly states "malunion" and that the encounter is subsequent to the initial fracture treatment.
• Verify that the fracture site is indeed the upper end of the tibia and that no further specificity regarding the physeal fracture type is available.
• Avoid using this code for initial fracture encounters or for nonunion, which has a distinct code.