In simple words: This code describes a follow-up visit for a broken fibula (the smaller bone in the lower leg) that is healing normally. The bone was broken in multiple places and the pieces moved out of alignment. The skin was not broken during the initial injury.

A displaced comminuted fracture, sometimes referred to as a multi-fragmentary fracture, of the shaft of an unspecified fibula refers to a break of the long cylindrical part of the smaller, outermost bone of the two bones of the lower leg, into three or more interconnected pieces, with misalignment of the fracture fragments. This is a subsequent encounter for a closed fracture with routine healing, meaning the skin is not broken and the fracture is healing as expected. The side of the fibula (right or left) is not specified.

Example 1: A patient returns for a follow-up appointment after sustaining a displaced comminuted fracture of the fibula in a motor vehicle accident two weeks prior. The fracture is closed and healing normally., A patient who fell from a ladder presents for a follow up visit four weeks after the injury. X-rays at the initial encounter demonstrated a displaced comminuted closed fracture to the shaft of the left fibula. The fracture is healing appropriately with no complications at this follow-up appointment., A patient presents to their orthopedist for a routine follow-up appointment. The patient had sustained a closed displaced comminuted fracture to the fibula after a skiing accident. Imaging shows the bone fragments are in good alignment, and there are no signs of infection.

Documentation should include the original injury date, type of fracture, treatment provided, and evidence of routine healing based on physical exam and imaging studies.