Unspecified fracture of lower end of right tibia, sequela

This code indicates a long-term complication or late effect stemming from an unspecified fracture of the distal end of the right tibia. It signifies that the initial acute injury has healed, but the patient is still experiencing residual issues directly attributable to that past fracture.

Apply this code when documenting a patient presenting with a chronic condition or complication (e.g., nonunion, malunion, chronic pain, deformity, functional limitation) that is a direct consequence of a previously sustained, but now healed, unspecified fracture of the lower end of the right tibia. This code is used after the initial acute phase of treatment for the fracture has concluded.

• Always use a seventh character of 'S' for sequela when the patient is being treated for a complication or late effect of a healed fracture.
• Code the specific nature of the sequela (e.g., M84.4x for malunion, M84.2x for nonunion) first, followed by this sequela code.
• Ensure documentation clearly links the current condition to the past right distal tibia fracture.