Nondisplaced Zone II fracture of sacrum, sequela

This code describes a fracture in the middle section of the sacrum (Zone II) that has healed or is no longer acute, and the bone fragments remain in their normal anatomical alignment. It signifies a long-term effect or complication arising from a previously sustained sacral fracture.

Use this code when documenting a patient presenting for follow-up care, evaluation of chronic pain, or assessment of residual symptoms directly attributable to a past, non-displaced Zone II sacral fracture. This code is appropriate when the initial acute injury has resolved and the current encounter addresses a sequela.

• Always assign a sequela code (7th character 'S') when the patient is seen for complications or conditions resulting from a previous injury, after the acute phase has passed.
• Do not use this code for initial encounters or active treatment of an acute fracture; instead, use the appropriate acute fracture code.
• Consider additional codes for specific sequelae, such as chronic pain (e.g., G89.29) or neurological deficits, if documented.