In simple words: This code refers to a follow-up visit for a broken wrist bone (radius) near the thumb. The break was originally an open fracture, meaning the bone went through the skin. The injury, classified as a Barton's fracture, is now healed, but it hasn't healed correctly (malunion). The break was a type IIIA, IIIB, or IIIC, indicating varying degrees of soft tissue damage.

This code describes a Barton's fracture, a fracture of the distal radius involving the wrist joint, which is open (meaning the bone broke through the skin) and has healed improperly (malunion). It specifies that this is a subsequent encounter for the fracture, and that the fracture is classified as type IIIA, IIIB, or IIIC according to the Gustilo open fracture classification. The Gustilo classification indicates the severity of the soft tissue injury associated with the fracture, ranging from minimal damage (IIIA) to extensive damage with significant vascular compromise (IIIC).

Example 1: A patient initially presented with an open Barton's fracture of the distal radius, classified as Gustilo type IIIB. The fracture required surgical intervention and internal fixation. This code (S52.569R) is used for a follow-up visit where the fracture has healed in a malunited position., A patient was previously treated for a Gustilo type IIIA open Barton’s fracture of their radius. They are now experiencing ongoing wrist pain and limited range of motion due to the malunion. They seek further medical attention. S52.569R accurately reflects the current situation., A patient suffered a severe injury resulting in a Gustilo type IIIC open Barton's fracture. During a subsequent visit, the physician determines that the fracture has healed with malunion. S52.569R is used as part of the diagnosis coding.

Documentation should include details of the initial injury, the type of open fracture (Gustilo classification), treatment provided, evidence of malunion (e.g., imaging studies, physical exam findings), and the patient’s current symptoms.