Stress fracture, unspecified site, sequela

This code signifies a stress fracture that occurred in the past and is now presenting with residual effects or complications. It indicates that the specific anatomical location of the original stress fracture is not documented or is unknown. The "sequela" designation means the current encounter is for a condition resulting from the previous stress fracture.

Use this code when a patient is being treated for a long-term consequence or late effect of a stress fracture, and the original fracture site is not specified in the medical record. Documentation should clearly indicate a prior stress fracture and the current condition being a direct result of it, such as chronic pain, deformity, or nonunion, without specifying the bone involved.

• Always attempt to identify the specific anatomical site of the stress fracture (e.g., M84.351S for stress fracture of the right tibia, sequela) before resorting to the unspecified code.
• This code requires a seventh character "S" for sequela, indicating that the current encounter is for the late effects of the stress fracture.
• Code first the specific sequela (e.g., chronic pain, malunion) if applicable, followed by this code to indicate the underlying cause.