Stress fracture, unspecified tibia and fibula, sequela

This code signifies a stress fracture affecting an unspecified tibia or fibula, where the fracture itself is no longer acute but rather represents a long-term complication or residual effect. This could include chronic pain, nonunion, malunion, or persistent functional impairment directly attributable to the past stress fracture.

Apply this code when documentation clearly indicates a healed or resolving stress fracture of the tibia or fibula, and the patient is presenting for treatment of a residual condition directly resulting from that fracture. The "S" seventh character indicates that the encounter is for sequelae, meaning the acute phase of the injury has passed.

• Ensure documentation explicitly links the current condition to a past stress fracture of the tibia or fibula.
• Do not use for acute stress fractures; refer to the appropriate M84.3- codes without the "S" seventh character.
• Always sequence this code after the primary diagnosis describing the specific sequela (e.g., chronic pain, nonunion).