Maxillary fracture, unspecified side, sequela

This code signifies a long-term complication or late effect resulting from a past fracture of the maxilla, where the specific side of the fracture (left or right) was not documented. It indicates that the initial acute injury has resolved, but the patient continues to experience issues directly attributable to that prior maxillary trauma.

Apply this code when documentation clearly states a patient is presenting for treatment of a sequela (e.g., malunion, nonunion, chronic pain, nerve damage, cosmetic deformity) directly linked to a previously sustained maxillary fracture. The medical record must explicitly indicate that the original fracture occurred in the maxilla, but the laterality was not specified.

• Always sequence the sequela code first, followed by a code describing the specific nature of the sequela (e.g., M84.28 for nonunion).
• Ensure documentation explicitly links the current condition to a previous maxillary fracture and specifies "unspecified side" if laterality is unknown.
• Do not use this code for acute maxillary fractures; refer to the acute S02.40- series for current injuries.