Injury of oculomotor nerve, unspecified side, sequela

This code signifies a long-term complication or late effect resulting from a past injury to the oculomotor nerve (cranial nerve III), affecting an unspecified side. The oculomotor nerve controls most eye movements, pupillary constriction, and eyelid elevation. Sequelae can include persistent strabismus, ptosis, diplopia, or pupillary abnormalities.

Apply this code when documenting a current condition that is a residual effect of a previous oculomotor nerve injury, and the specific side of the injury is not documented or is unknown. This code is appropriate for follow-up encounters where the acute injury has resolved, but its lasting impact is still being treated or evaluated. Documentation should clearly link the current neurological deficit to a prior oculomotor nerve trauma.

• Always sequence this sequela code first, followed by a code describing the specific residual condition (e.g., H49.00 for third nerve palsy, unspecified).
• Ensure documentation explicitly states "sequela," "late effect," or indicates a chronic condition resulting from a past injury.
• Avoid using this code for acute or current injuries; instead, use the appropriate acute injury code (S04.1- without the "S" seventh character).