Displaced bimalleolar fracture of unsp lower leg, sequela

This code signifies a previously sustained bimalleolar fracture of an unspecified lower leg that was displaced and is now in a healing or healed state, with residual effects or complications. It indicates that the fracture is no longer acute but continues to impact the patient's condition.

Apply this code when documenting follow-up care for a patient with a history of a displaced bimalleolar fracture of an unspecified lower leg, and the encounter addresses a sequela (e.g., malunion, nonunion, pain, limited range of motion, hardware complications) directly related to that past injury. This is appropriate for encounters occurring after the initial healing phase.

• Always use this code as a secondary diagnosis, following a primary code that describes the specific sequela being treated.
• Ensure documentation clearly links the current condition to the prior displaced bimalleolar fracture.
• Verify that the laterality (left or right leg) is truly unspecified in the medical record before selecting this code.