Incomplete atypical femoral fracture, unsp leg, sequela

This code describes a stress fracture of the femur that is considered "atypical" due to its specific characteristics, such as a transverse or oblique fracture pattern, minimal or no trauma, and often bilateral involvement. It is an incomplete fracture, meaning the bone is not fully broken through, and the "S" indicates it is a sequela, meaning a late effect or complication of a previous injury or condition.

Use this code for patients presenting with a documented incomplete atypical femoral fracture where the specific leg (left or right) is not identified, and the current encounter is for the management of a long-term complication or residual effect of this fracture. This often applies to follow-up care after initial treatment or when addressing persistent symptoms related to the fracture. Documentation should clearly state "incomplete atypical femoral fracture," specify "unspecified leg," and indicate that the encounter is for a sequela.

• Ensure documentation explicitly states "incomplete" and "atypical" to differentiate from other femoral fractures.
• The "S" seventh character indicates sequela; do not use for initial or subsequent encounters for active treatment of the acute fracture.
• Confirm the unspecified laterality is clearly documented; otherwise, use a more specific code for the left or right leg.