Maxillary fracture, left side, sequela

This code signifies a long-term complication or residual effect stemming from a prior fracture of the left maxilla. It indicates that the patient is experiencing ongoing issues directly attributable to the healed or previously treated maxillary fracture on the left side. These sequelae can include chronic pain, malunion, nonunion, nerve damage, or persistent cosmetic deformity.

Use this code when documenting a patient presenting with a current condition that is a direct consequence of a past left maxillary fracture. The medical record should clearly state the link between the current problem and the previous injury. This code is appropriate for follow-up visits addressing these chronic issues, not for the initial acute fracture treatment.

• Always sequence the sequela code first, followed by a code describing the specific nature of the sequela (e.g., M26.0 for maxillary anomalies of jaw-cranial base relationship).
• Ensure documentation explicitly states "sequela of" or "due to prior" left maxillary fracture to support code assignment.
• Do not use this code for acute or active left maxillary fractures; use codes from the S02.41- series for those instances.