Injury of facial nerve, left side, initial encounter

This code signifies a traumatic injury to the facial nerve (cranial nerve VII) on the left side of the face. Such an injury can result in facial paralysis, weakness, or sensory disturbances affecting the muscles of facial expression, taste sensation, and tear/salivary gland function. This specific code is for the initial treatment or active phase of care for this injury.

Apply this code when documentation clearly indicates a new, acute injury to the left facial nerve due to trauma, such as a fracture, laceration, or blunt force. Supporting documentation should specify the side affected (left) and confirm the injury is recent or in its active treatment phase. This code is appropriate for the initial hospital stay, emergency department visit, or first outpatient encounter for this specific injury.

• Ensure documentation specifies "left side" of the facial nerve. If unspecified, an unspecified laterality code would be more appropriate.
• Confirm the "initial encounter" status; subsequent care for the same injury would require a different seventh character (e.g., S04.52XD for subsequent encounter).
• Always code the underlying cause of the injury (e.g., fracture, open wound) in addition to this code, following ICD-10-CM sequencing guidelines.