Sltr-haris Type IV physeal fx upper end of r tibia, sequela

This code signifies a chronic or late-stage complication arising from a Salter-Harris Type IV fracture affecting the growth plate at the top of the right shin bone. This type of fracture involves both the epiphysis and metaphysis, extending through the physis, and carries a higher risk of growth disturbance. The "sequela" designation indicates that the current encounter addresses a long-term consequence of the original injury, such as growth arrest, angular deformity, or chronic pain.

Use this code when documenting follow-up care for a patient who previously sustained a Salter-Harris Type IV fracture of the proximal right tibia and is now presenting with a residual condition or complication directly attributable to that past injury. This includes encounters for evaluating growth plate arrest, limb length discrepancy, malunion, or persistent functional limitations years after the initial fracture. Do not use for the initial treatment of the acute fracture.

• Always assign an additional code to specify the exact nature of the sequela (e.g., M21.621 for genu valgum, M89.311 for hypertrophy of bone).
• Ensure documentation clearly links the current condition to the past Salter-Harris Type IV fracture of the right tibia.
• Verify laterality (right tibia) is accurately reflected in the code.