Injury of oculomotor nerve, left side, sequela

This code signifies a long-term or late effect resulting from a past injury to the oculomotor nerve on the left side. The oculomotor nerve (cranial nerve III) controls most eye movements, pupillary constriction, and eyelid elevation. Sequelae can manifest as persistent diplopia, ptosis, or ophthalmoplegia.

Apply this code when documentation clearly indicates a residual condition directly attributable to a previous injury of the left oculomotor nerve, and the patient is presenting for treatment of this long-term effect. The medical record should specify the left side and confirm the injury as the etiology of the current symptoms.

• Always use a sequela code (ending in "S") as a secondary diagnosis, following the code for the specific sequela itself (e.g., H49.02 for third nerve palsy, left eye).
• Ensure the documentation explicitly states "sequela," "late effect," or describes a condition resulting from a past injury to the oculomotor nerve.
• Differentiate from acute injuries (S04.12XA) or subsequent encounters for active treatment of the injury (S04.12XD).