Nondisplaced bimalleolar fracture of r low leg, sequela

This code signifies a long-term complication or late effect resulting from a previously sustained nondisplaced fracture involving both the medial and lateral malleoli of the right ankle. It indicates that the initial injury has healed, but the patient is now experiencing a residual condition directly attributable to that fracture.

Use this code when documenting a current condition that is a sequela of a healed nondisplaced bimalleolar fracture of the right lower leg. This would apply when the patient presents for treatment of chronic pain, stiffness, deformity, or other persistent issues directly linked to the old fracture, and the acute phase of the fracture has passed.

• Always sequence the sequela code first, followed by codes for the specific residual condition(s) being treated.
• Ensure documentation clearly links the current condition to the previous bimalleolar fracture.
• Verify that the fracture was indeed nondisplaced and involved both malleoli of the right lower leg.