In simple words: This code describes a follow-up visit for a hip fracture that is not healing as expected. The fracture is in the middle of the bone that connects the hip to the thigh, and the broken bone was exposed through a skin wound at the time of the initial injury.

A nondisplaced midcervical fracture of an unspecified femur, which may also be called a transcervical fracture of the femur, refers to a break between the ball of the hip joint, or the femoral head, and the thigh bone’s shaft at the middle of the neck connecting these structures, caused by trauma such as a road traffic accident, falls, sports injury, or low bone density; type I or II refers to the Gustilo classification for open long bone fractures. The provider does not document whether the fracture involves the right or left femur at this subsequent encounter for delayed healing of an open fracture exposed through a tear or laceration of the skin caused by external injury.

Example 1: A patient is seen for follow-up after surgical treatment of an open, type II midcervical femur fracture. The fracture is healing slower than expected, and the patient is experiencing ongoing pain and limited mobility., A patient who sustained an open, type I midcervical femur fracture in a motor vehicle accident presents for a follow-up visit. The wound has not healed properly, and there are signs of infection., A patient is being managed non-operatively for a nondisplaced midcervical femur fracture that was open, type I.They present for a scheduled follow-up, and repeat imaging shows evidence of delayed healing.

Documentation should include details of the initial injury, type of fracture (Gustilo classification), treatment provided, evidence of delayed healing (e.g., imaging reports, clinical findings), and any complications.

** This code is specifically for subsequent encounters related to delayed healing of open type I or II midcervical femur fractures. Other codes exist for initial encounters (S72.031-, S72.032-) and for other types of open fractures (S72.035-).