Other specified injury of right vertebral artery, sequela

This code signifies a long-term complication or residual effect stemming from a previously sustained injury to the right vertebral artery. This could include chronic dissection, pseudoaneurysm, stenosis, or other persistent vascular compromise that developed as a direct result of the initial trauma. The injury has resolved, but its lasting impact on the patient's health is still present.

Apply this code when documentation clearly indicates a current condition or symptom directly attributable to an old injury of the right vertebral artery. This typically occurs after the acute phase of the injury has passed and the patient is experiencing ongoing sequelae. Documentation should specify the nature of the sequela and its causal link to the prior vertebral artery trauma.

• Always assign a sequela code (ending in "S") as a secondary diagnosis, following the code for the specific sequela itself (e.g., I72.5 for pseudoaneurysm).
• Ensure the medical record explicitly states the injury is "old," "healed," or describes a "late effect" or "sequela" to justify the "S" seventh character.
• Distinguish from acute injuries (A, D) or subsequent encounters for routine care during the healing phase (G, K, P).