Sltr-haris Type IV physl fx upr end unsp tibia, 7thP

This code signifies a complex growth plate fracture (Salter-Harris Type IV) affecting the top portion of the shin bone, where the fracture has healed incorrectly (malunion). This specific code is used when the patient is seen for follow-up care related to this malunited fracture, not for the initial injury or routine healing.

This code is appropriate for encounters where a patient presents with complications or ongoing issues stemming from a previously sustained Salter-Harris Type IV physeal fracture of the proximal tibia that has healed with a deformity. This includes assessments for corrective surgery, physical therapy for malunion-related functional deficits, or monitoring of growth disturbances.

• Ensure documentation clearly specifies "malunion" and that the encounter is subsequent to the initial fracture treatment.
• Verify the fracture type is Salter-Harris Type IV and the location is the upper end of the tibia.
• Do not use this code for initial fracture treatment or for nonunion; separate codes exist for those scenarios.