Puncture wound without foreign body of unsp ear, sequela

This code signifies a puncture injury to an unspecified ear that occurred in the past, and the patient is now presenting for treatment of a residual effect or complication from that original injury. It specifically excludes cases where a foreign object remains embedded in the ear.

Apply this code when documentation indicates a patient is being treated for a long-term consequence (sequela) of a previously sustained puncture wound to an ear, and the specific ear (left or right) is not documented. Examples include chronic pain, scarring, or hearing loss directly attributable to the past puncture. The medical record must clearly link the current condition to the prior injury.

• Ensure the documentation explicitly states the current condition is a "sequela" or "due to a previous injury" to justify the 7th character 'S'.
• Do not use this code for initial encounters or subsequent encounters for active treatment of the acute puncture wound; those require different 7th characters.
• Always code the specific sequela (e.g., H90.x for hearing loss, L90.5 for scar conditions) first, followed by this code as a secondary diagnosis to indicate the cause.