Injury of abducent nerve, unspecified side, init encntr

This code describes an injury to the abducens nerve (cranial nerve VI), which controls the lateral rectus muscle responsible for outward eye movement. An injury to this nerve typically results in diplopia (double vision) and esotropia (inward turning of the eye) due to the inability to abduct the affected eye. This specific code is used when the laterality of the injury is not documented.

Use this code for initial encounters when a patient presents with a newly diagnosed or treated injury to the abducens nerve, and the medical record does not specify whether the injury is to the left or right side. Documentation should clearly indicate an injury to cranial nerve VI, often presenting with symptoms like horizontal diplopia or limited eye abduction.

• Do not use this code if the laterality (left or right) of the abducens nerve injury is documented; instead, select a more specific code.
• Ensure documentation supports an "initial encounter" for treatment of the injury, not a subsequent visit for follow-up care.
• Consider co-reporting with external cause codes (V00-Y99) to describe the circumstances of the injury, if known.