Pathological fracture, left tibia, sequela

This code signifies a pathological fracture of the left tibia that has resulted in a long-term complication or late effect. It indicates that the fracture was caused by an underlying disease process, not by trauma, and the patient is now experiencing a residual condition directly related to that fracture.

Apply this code when documentation clearly indicates a pathological fracture of the left tibia, and the current encounter addresses a sequela (e.g., malunion, nonunion, chronic pain, deformity) that occurred as a direct consequence of that fracture. This code is appropriate for follow-up care of such chronic conditions after the initial fracture has healed or is no longer in the acute phase.

• Ensure documentation explicitly states "pathological fracture" and specifies the left tibia.
• The "S" seventh character indicates a sequela, meaning the acute phase of the fracture has passed. Do not use for active fracture treatment.
• Always code the underlying disease causing the pathological fracture first, if known and still relevant to the encounter.