Disp fx of medial malleolus of unspecified tibia, sequela

This code signifies a past injury involving a fracture of the inner ankle bone (medial malleolus) of the tibia, where the bone fragments were not properly aligned. The specific side (left or right) of the tibia is not documented. This code is used to report the long-term effects or complications arising from this previously healed fracture.

Apply this code when a patient presents for treatment of a condition directly resulting from a healed, displaced medial malleolus fracture of an unspecified tibia. Examples include chronic pain, limited range of motion, post-traumatic arthritis, or nonunion/malunion complications that are being addressed in a subsequent encounter after the initial fracture has healed.

• Ensure documentation clearly states the encounter is for a sequela of a healed fracture, not an active fracture.
• This "S" seventh character indicates sequela; do not use for initial or subsequent encounters for active treatment of the fracture itself.
• If the laterality (left or right tibia) is documented, a more specific code should be used.