Pathological fracture, left toe(s), sequela

This code signifies a fracture of one or more toes on the left foot that occurred due to an underlying disease process, rather than trauma, and is now presenting with a residual condition or complication. It indicates that the acute phase of the pathological fracture has passed, and the patient is experiencing a long-term effect.

Apply this code when documentation clearly states a left toe fracture resulted from a pathological condition (e.g., osteoporosis, tumor, metabolic bone disease) and the patient is being treated for a sequela of that fracture. This includes nonunion, malunion, chronic pain, or functional impairment directly attributable to the past pathological fracture. The medical record should specify "sequela" or indicate a chronic condition resulting from the original pathological fracture.

• Always sequence this code after the code identifying the specific sequela (e.g., M84.478S for nonunion of a pathological left toe fracture, followed by M84.478S).
• Distinguish from acute pathological fractures (M84.4-) and stress fractures (M84.3-).
• Ensure laterality is explicitly documented as "left toe(s)" to support this specific code.