Stress fracture, left tibia, sequela

This code signifies a stress fracture of the left tibia where the acute injury has resolved, but the patient is still experiencing residual effects or complications directly attributable to the original fracture. These sequelae could include chronic pain, nonunion, malunion, or persistent functional limitations.

Apply this code when documentation clearly indicates a history of a stress fracture in the left tibia and the current encounter addresses a long-term complication or residual condition stemming from that past fracture. This is appropriate when the initial fracture has healed, but its lasting impact is the focus of treatment.

• Ensure documentation explicitly states "sequela" or describes a chronic condition directly resulting from a resolved left tibial stress fracture.
• Do not use for acute or initial treatment of a stress fracture; use an acute stress fracture code (e.g., M84.362A) for the initial injury.
• Always sequence this code after any codes describing the specific sequela (e.g., chronic pain, nonunion) if applicable.