Breakdown of int fix of bone of l low leg, sequela

This code indicates a long-term complication where an internal fixation device, such as a plate, screw, or rod, implanted in the bone of the patient's left lower leg (tibia or fibula) has mechanically failed. This failure could manifest as bending, breaking, loosening, or migrating of the device, occurring after the initial healing phase of the fracture or osteotomy.

Use this code when documenting a patient presenting with symptoms or radiographic evidence of a mechanical failure of an internal fixation device in their left lower leg, and this issue is a sequela, meaning it's a late effect or consequence of the original injury or surgery. This applies to follow-up encounters for managing such a breakdown, not the initial event.

• This "S" encounter code is for sequelae, indicating a late effect of the mechanical breakdown.
• Always code the underlying reason for the original fixation (e.g., fracture) as an additional diagnosis, if still relevant.
• Specify the exact type of internal fixation device if known and documented in the medical record.