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

This code signifies a Salter-Harris Type II fracture affecting the growth plate at the distal end of the right tibia, with the patient currently experiencing long-term effects or complications from this past injury. A Type II fracture involves the physis and a portion of the metaphysis, sparing the epiphysis. The "sequela" indicates that the acute injury has healed, but residual problems persist.

Apply this code when documentation clearly indicates a history of a Salter-Harris Type II fracture of the lower right tibia, and the patient is presenting for treatment of a current condition directly resulting from that old injury. Examples include growth disturbances, angular deformities, or chronic pain attributed to the previous fracture. Do not use for the initial acute injury.

• Always ensure the documentation explicitly states "sequela" or describes a chronic condition directly linked to the past fracture.
• Verify laterality (right tibia) and the specific Salter-Harris type (Type II) are accurately documented.
• This code is for the sequela of the fracture; an additional code for the specific manifestation of the sequela (e.g., M21.061 for valgus deformity of right tibia) should also be reported.