Other fracture of shaft of right tibia, sequela

This code signifies a long-term complication or residual effect stemming from a previous fracture of the shaft of the right tibia, excluding specific types like spiral or transverse. It indicates that the initial acute injury has healed, but the patient continues to experience issues directly attributable to that past fracture.

This code is appropriate for documenting conditions such as malunion, nonunion, chronic pain, deformity, or functional limitations that persist after the acute phase of a right tibial shaft fracture has passed. It should be used when the patient is no longer in the active treatment phase for the initial fracture but is being treated for its lasting consequences.

• Always assign an additional code to specify the nature of the sequela (e.g., M84.2x for nonunion, M96.0 for malunion).
• Ensure documentation clearly links the current condition to the previous right tibial shaft fracture.
• Do not use this code for initial or subsequent encounters for active fracture treatment; it is exclusively for sequelae.