Nondisp comminuted fracture of shaft of right tibia, sequela

This code describes a long-term complication or late effect stemming from a comminuted fracture of the shaft of the right tibia, where the bone fragments remain in their anatomical position. It indicates that the initial injury has resolved, but the patient is still experiencing residual problems directly attributable to that fracture.

Use this code when documenting a patient presenting with a current condition or symptom that is a direct consequence of a previously healed or treated nondisplaced comminuted fracture of the right tibial shaft. Examples include chronic pain, stiffness, nonunion, malunion, or functional limitations occurring months or years after the initial injury.

• Always assign a secondary code for the specific sequela (e.g., chronic pain, malunion) in addition to this code.
• Ensure documentation clearly links the current condition to the previous right tibial shaft fracture.
• Do not use this code for initial encounters or subsequent encounters for active treatment of the acute fracture.