Pathological fracture, left ankle, sequela

This code signifies a fracture of the left ankle that occurred due to an underlying disease process, rather than significant trauma, and is now being treated for its long-term effects or complications. It indicates that the acute phase of the pathological fracture has passed, and the current encounter addresses residual issues.

Apply this code when a patient presents for treatment of a complication or late effect directly resulting from a previously sustained pathological fracture of the left ankle. Documentation should clearly state that the fracture was pathological and that the current visit addresses a sequela, such as malunion, nonunion, chronic pain, or functional limitation.

• Ensure documentation explicitly states "pathological fracture" and specifies the left ankle.
• This "S" seventh character indicates sequela; do not use for initial or subsequent encounters for active treatment of the fracture.
• Code the underlying condition causing the pathological fracture first, if known and still relevant to the current encounter.