Unspecified injury of unspecified vertebral artery, sequela

This code signifies a long-term effect or complication resulting from a past, unspecified injury to an unspecified vertebral artery. It indicates that the acute phase of the injury has passed, and the patient is now experiencing residual issues directly attributable to that original trauma.

Apply this code when documentation clearly indicates a sequela (e.g., chronic pain, neurological deficit, vascular insufficiency) stemming from a previous, unspecific injury to a vertebral artery, and the specific artery (left or right) is not documented. This code is appropriate for follow-up encounters where the sequela is being treated or evaluated.

• Requires a seventh character 'S' to denote sequela, indicating the residual effect of a past injury.
• Only use when the specific vertebral artery (left or right) is not documented; otherwise, use a more specific code.
• Always code the sequela (e.g., chronic pain, neurological deficit) first, followed by this code to indicate the cause.