Unspecified injury of right middle and inner ear, sequela

This code signifies a long-term complication or late effect stemming from an unspecified injury to the right middle and inner ear. It indicates that the initial traumatic event has resolved, but residual symptoms or conditions related to the ear injury persist. This could include chronic hearing loss, tinnitus, or balance issues directly attributable to the past injury.

Use this code when documentation clearly indicates a sequela (late effect) of a prior, unspecified injury to the right middle and inner ear. This applies when the acute phase of the injury has passed, and the patient is presenting for treatment or evaluation of the lasting consequences. The medical record should explicitly link the current condition to a past ear trauma.

• Always sequence the sequela code first, followed by codes for the specific residual condition (e.g., hearing loss, tinnitus).
• Ensure the documentation specifies "right" ear; otherwise, an unspecified laterality code should be considered.
• Avoid using this code for acute injuries; instead, use the appropriate acute injury code with the correct seventh character.