Sltr-haris Type II physeal fx upper end of r tibia, sequela

This code signifies a Salter-Harris Type II fracture affecting the growth plate at the top of the right shin bone, where the fracture line extends through the metaphysis. The "sequela" designation indicates that this code is used for conditions or complications arising as a direct result of the initial fracture, after the acute phase of injury has passed. This could include issues like growth arrest, angular deformity, or chronic pain.

This code is appropriate when documenting a long-term complication or residual effect stemming from a previously sustained Salter-Harris Type II fracture of the proximal right tibia. It should be used when the patient is presenting for treatment of a problem directly attributable to the old fracture, rather than for the initial acute injury. Examples include follow-up for leg length discrepancy or malunion.

• Always ensure documentation clearly links the current condition to the prior Salter-Harris Type II fracture of the right proximal tibia.
• Do not use this code for the initial acute fracture; a separate acute fracture code would be used at that time.
• Consider additional codes for specific sequelae (e.g., malunion, nonunion, growth disturbance) if documented.