Nondisp fx of lesser tuberosity of unsp humerus, sequela

This code signifies a healed or residual condition resulting from a prior nondisplaced fracture of the lesser tuberosity of the humerus, where the specific side (left or right) is not documented. It indicates that the acute phase of the injury has passed, and the patient is now experiencing a long-term effect or complication related to the original fracture.

Use this code for follow-up encounters when a patient presents with ongoing issues, pain, or functional limitations directly attributable to a previously sustained nondisplaced lesser tuberosity fracture, and the laterality is unspecified. This is appropriate for documenting the sequela of the original injury, not the acute fracture itself.

• Ensure documentation clearly supports the "sequela" nature of the encounter, indicating a long-term effect rather than an acute injury.
• Verify that the fracture was indeed nondisplaced and involved the lesser tuberosity.
• Only use this code when the laterality of the humerus is explicitly unspecified in the medical record. If laterality is known, a more specific code should be used.