3-part fracture of surgical neck of right humerus, sequela

This code signifies a chronic or late-occurring complication resulting from a 3-part fracture of the surgical neck of the right humerus. These sequelae can include persistent pain, limited range of motion, nonunion, malunion, or post-traumatic arthritis, manifesting long after the initial healing phase.

Use this code when documenting conditions that are a direct consequence of a previously sustained 3-part fracture of the surgical neck of the right humerus, and these conditions are being treated or evaluated at a later encounter. This applies when the acute phase of the fracture has passed, and the patient presents with residual problems attributable to the original injury.

• Always assign an additional code to specify the exact nature of the sequela (e.g., M25.511 for pain in right shoulder, M96.0 for pseudarthrosis after fusion).
• Ensure documentation clearly links the current condition to the historical 3-part surgical neck fracture of the right humerus.
• Do not use this code for initial or subsequent encounters during the active treatment of the acute fracture.