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

This code signifies a past injury involving a four-part fracture of the surgical neck of the right humerus, where the patient is now experiencing ongoing complications or late effects related to that original fracture. A four-part fracture indicates significant displacement and involvement of multiple fragments, often including the humeral head, greater tuberosity, and lesser tuberosity, in addition to the surgical neck. The "sequela" designation means the acute phase of the fracture has passed, and the current encounter addresses a residual problem.

Use this code for encounters where a patient presents with a long-term complication, such as malunion, nonunion, chronic pain, limited range of motion, or post-traumatic arthritis, stemming from a previously treated four-part surgical neck fracture of the right humerus. This code is appropriate when the initial fracture has healed or is in the process of healing, but the patient continues to experience issues directly attributable to the prior injury. Do not use this code for the initial treatment of the acute fracture.

• Always assign an additional code to specify the nature of the sequela (e.g., M84.0x for malunion, M25.511 for chronic right shoulder pain).
• Ensure documentation clearly indicates the fracture occurred in the past and the current encounter addresses a residual effect, not the acute injury.
• Verify the laterality (right humerus) and the specific fracture type (four-part surgical neck) are accurately documented.