Pathological fracture in other disease, left tibia, sequela

This code signifies a pathological fracture of the left tibia that has occurred due to an underlying disease process, not from trauma. The "sequela" seventh character indicates that this encounter is for the late effects or complications of the fracture, after the initial healing is complete. This could involve ongoing pain, nonunion, malunion, or functional impairment directly attributable to the past fracture.

Use this code when a patient presents for treatment or evaluation of a long-term complication or residual effect stemming from a previously healed or resolved pathological fracture of the left tibia. Documentation should clearly state the fracture's pathological origin (e.g., due to osteoporosis, tumor, Paget's disease) and that the current encounter addresses a sequela, not the initial fracture treatment or routine follow-up during active healing.

• Always assign an additional code for the underlying disease causing the pathological fracture.
• Distinguish carefully between active fracture treatment (initial, subsequent, or delayed healing) and sequela; the seventh character is crucial.
• Ensure documentation explicitly supports the "sequela" status, indicating the fracture itself is no longer acute.