Nondisp spiral fracture of shaft of right tibia, sequela

This code signifies a previous injury involving a spiral fracture of the shaft of the right tibia that has since healed or is in the process of healing, with no displacement of the bone fragments. The "sequela" designation indicates that this code is used to report conditions that are the late effects of the original fracture, such as pain, stiffness, or deformity, after the acute phase of healing has passed.

Use this code when documenting or billing for ongoing care related to the long-term effects of a previously sustained, nondisplaced spiral fracture of the right tibial shaft. This applies to follow-up visits where the primary focus is on managing residual symptoms or complications directly attributable to the old fracture, rather than the initial acute injury.

• Ensure the medical record clearly documents the "sequela" aspect, indicating the current condition is a late effect of the fracture.
• Do not use this code for the initial treatment of the acute fracture; a different code would be used for the active injury.
• Always review the full patient history to confirm the fracture was indeed nondisplaced and located in the shaft of the right tibia.