Nondisplaced pilon fracture of right tibia, sequela

This code describes a previous injury to the right tibia, specifically a nondisplaced pilon fracture, where the patient is now experiencing residual effects or complications. A pilon fracture involves the weight-bearing surface of the distal tibia, at the ankle joint. "Nondisplaced" indicates the bone fragments were in their anatomical position at the time of the initial fracture.

This code is appropriate when a patient presents with ongoing issues directly attributable to a healed or healing nondisplaced pilon fracture of the right tibia. Examples include chronic pain, stiffness, limited range of motion, or post-traumatic arthritis in the ankle joint resulting from the original injury. It should be used for follow-up encounters after the initial acute treatment phase has concluded.

• Always use an additional code to specify the nature of the sequela (e.g., M25.571 for pain in right ankle and foot, M19.171 for post-traumatic osteoarthritis of right ankle).
• Ensure documentation clearly links the current condition to the past pilon fracture of the right tibia.
• Do not use this code for the initial acute fracture treatment; use the appropriate acute fracture code for that phase of care.