LeFort I fracture, sequela

This code signifies a long-term complication or late effect directly resulting from a previously sustained LeFort I fracture. A LeFort I fracture is a horizontal fracture of the maxilla, separating the palate and alveolar process from the rest of the facial skeleton. The sequela could manifest as malunion, nonunion, chronic pain, nerve damage, or functional impairment.

Apply this code when documentation clearly indicates a current condition or symptom is a direct consequence of a healed or resolving LeFort I fracture, occurring after the acute phase of injury. This is typically used for follow-up encounters addressing persistent issues related to the original fracture. Documentation should specify the nature of the sequela and its causal link to the prior LeFort I fracture.

• Always sequence the sequela code first, followed by codes for the specific manifestation of the sequela (e.g., malunion, chronic pain).
• Ensure the medical record explicitly states the condition is a "sequela," "late effect," or "due to old injury" of a LeFort I fracture.
• Do not use this code for acute or active LeFort I fractures; use the appropriate acute fracture code.