Nondisp transverse fracture of shaft of left tibia, sequela

This code signifies a healed or residual condition resulting from a nondisplaced transverse fracture of the shaft of the left tibia. It indicates that the fracture itself is no longer acute, but the patient is still experiencing symptoms or complications directly attributable to the previous injury.

Apply this code when documenting follow-up care for a patient who previously sustained a nondisplaced transverse fracture of the left tibial shaft and is now presenting with a sequela, such as chronic pain, malunion, nonunion, or functional limitations. This code is appropriate for encounters occurring after the initial healing phase of the fracture.

• Always sequence the sequela code first, followed by any codes for the specific manifestation of the sequela (e.g., chronic pain, malunion).
• Ensure documentation clearly links the current condition to the previous left tibial shaft fracture.
• Do not use this code for acute fractures or for routine follow-up without a documented sequela.