Maxillary fracture, right side, sequela

This code signifies a long-term complication or residual effect stemming from a previous fracture of the right maxilla. These sequelae can include chronic pain, malunion, nonunion, nerve damage, or persistent functional impairment of the jaw or facial structures. It indicates that the acute phase of the fracture has passed, and the patient is now experiencing ongoing issues directly attributable to the original injury.

Apply this code when documentation clearly indicates a current condition or symptom that is a direct consequence of a healed or previously treated right maxillary fracture. This is appropriate for follow-up visits addressing chronic issues, reconstructive surgeries for deformities caused by the fracture, or management of persistent pain or neurological deficits. Supporting documentation should explicitly link the current problem to the prior fracture.

• Always sequence this code after the code for the specific sequela (e.g., M26.4 for malocclusion due to malunion).
• Do not use this code for acute or active right maxillary fractures; those require codes from the S02.4- series without the "S" seventh character.
• Ensure the medical record explicitly states the laterality (right side) and the causal link between the current condition and the past fracture.