Injury of nerve root of cervical spine, sequela

This code signifies a long-term or late-effect complication resulting from a past injury to a nerve root originating from the cervical spine. It indicates that the initial nerve root injury has resolved, but the patient continues to experience residual symptoms or conditions directly attributable to that prior trauma.

Apply this code when documentation clearly indicates a current condition, such as chronic pain, weakness, or sensory deficits, that is a direct consequence of a previously sustained cervical nerve root injury. This code is appropriate for encounters addressing these persistent issues, not the initial acute injury. Documentation should specify the nature of the sequela and link it to the prior cervical nerve root trauma.

• Always use this code as a secondary diagnosis, following the code for the specific residual condition (e.g., chronic pain, muscle weakness).
• Ensure the medical record explicitly states the current condition is a "sequela," "late effect," or "due to old injury" of a cervical nerve root.
• Distinguish from acute or subacute nerve root injuries, which would be coded with an active injury code, not a sequela code.