Path fracture in neoplastic disease, l shoulder, sequela

This code signifies a pathological fracture of the left shoulder that occurred due to an underlying neoplastic disease, with the patient now experiencing a sequela (late effect) of that fracture. This indicates that the acute phase of the fracture has passed, and the patient is being treated for a residual condition or complication directly resulting from the previous pathological fracture.

Use this code when documentation clearly indicates a healed or healing pathological fracture of the left shoulder, caused by a neoplasm, and the patient is presenting for treatment of a long-term complication or residual effect of that fracture. Examples include chronic pain, nonunion, malunion, or functional impairment directly attributable to the past fracture. The medical record must specify the left shoulder and the sequela status.

• Always code the underlying neoplastic disease first, followed by this code for the sequela of the pathological fracture.
• Do not use this code for an acute pathological fracture; use the appropriate acute fracture code (e.g., M84.512A-D).
• Ensure documentation specifies "sequela" or a late effect of the fracture, rather than an active, acute fracture.