Pathological fracture, right tibia, sequela

This code signifies a bone fracture in the right tibia that occurred due to an underlying disease process, rather than significant trauma. The "sequela" seventh character indicates that this encounter is for the late effects or complications of the pathological fracture, after the initial healing phase.

Apply this code when a patient presents for treatment of long-term complications, nonunion, malunion, or other residual issues directly resulting from a previously healed or ongoing pathological fracture of the right tibia. Documentation should clearly state the pathological nature of the original fracture and the current encounter's focus on its sequelae.

• Always use a seventh character for fracture codes; "S" is for sequela.
• Code first the underlying disease causing the pathological fracture, if still active and relevant to the sequela.
• Distinguish from acute pathological fractures (A, D, G, K, P) or non-pathological traumatic fractures.