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2025 ICD-10-CM code M84.471S

Sequela of a pathological fracture of the right ankle. This refers to a fracture caused by an underlying disease, not trauma.

Do not use this code for the initial encounter for the fracture. Use the appropriate 7th character to indicate the encounter (e.g., A, D, G).Use a subsequent encounter code for the sequela.

Medical necessity is established by the underlying disease causing the fracture and the subsequent functional limitations resulting from the sequela.Documentation should link the current symptoms and limitations directly to the prior pathological fracture.

Clinicians diagnosing this condition typically rely on a combination of patient history, physical examination, and imaging studies (X-rays, MRI, CT scans).Laboratory tests to assess bone health and biopsies to examine bone tissue may also be used. Treatment focuses on managing pain, stabilizing the fracture, addressing the underlying disease, and physical therapy for rehabilitation.

In simple words: This code is used to document the long-term effects of a broken right ankle that happened due to a bone disease, not an accident.

This code describes the aftereffects or long-term consequences of a pathological fracture of the right ankle.A pathological fracture occurs when a bone breaks due to weakness caused by a disease process, such as osteoporosis, infection, or a tumor, rather than due to an injury. The "sequela" designation signifies that the code is being used to report the lasting effects of the fracture, not the acute phase of the fracture itself.

Example 1: A patient with a history of osteoporosis experiences a sudden pain in their right ankle while walking. An X-ray reveals a fracture, and code M84.471S is used to describe the condition as a pathological fracture sequela., A patient with bone cancer develops a fracture in their right ankle. This is a pathological fracture, and M84.471S would be used to report the subsequent encounter for the sequela., A patient experiences a pathological fracture in their right ankle due to Paget’s disease of bone.Years later, the patient continues to have pain and limited mobility in the ankle.M84.471S is used to represent the sequela.

Documentation should clearly indicate that the fracture is pathological (due to underlying disease) and not traumatic.The specific underlying condition should be documented as well. Documentation of the sequela itself, such as ongoing pain, limited mobility, or deformity, is crucial for using this code.

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