In simple words: This code describes a follow-up visit for a minor, open fracture of a small part of the left hip bone (lesser trochanter) that is healing normally. The fracture did not displace the bone and is a type I or II open fracture according to the Gustilo classification.

A nondisplaced fracture of the lesser trochanter of the left femur (thigh bone) refers to a break in the small, conical bony projection at the lower back part of the base of the femoral neck, without misalignment of the fracture fragments. This occurs as a result of high-impact trauma such as a direct blow sustained during a fall, crush injury, motor vehicle accident, or sports incidents. This code applies to a subsequent encounter for a normally healing, Gustilo classification-based type I or II fracture exposed through a tear or laceration of the skin.

Example 1: A patient presents for a follow-up appointment after sustaining an open fracture of the lesser trochanter of the left femur in a motor vehicle accident two weeks prior. The fracture is healing normally and is classified as a Gustilo type I open fracture., A patient who fell from a ladder and sustained a type II open fracture of the left lesser trochanter, is now being seen for their post-operative follow-up visit 4 weeks later. The wound is healing appropriately and the patient will continue with physical therapy., A football player was tackled and sustained an open fracture to his lesser trochanter of the left femur. He is seen in the office 2 weeks later to check on the healing. Imaging shows the fracture is healing without complications and is identified as a Gustilo type II fracture.

Documentation should include the type of fracture (open, nondisplaced), location (lesser trochanter of left femur), cause of injury, Gustilo classification, treatment provided, and the patient's progress.