Unspecified injury of lung, bilateral, subsequent encounter

This code signifies an unspecified injury affecting both lungs, where the specific nature of the trauma is not documented. It is used when a patient is receiving follow-up care for such an injury, after the initial treatment has been rendered.

This code is appropriate for subsequent encounters when a patient presents for ongoing management, monitoring, or rehabilitation of a bilateral lung injury that was not precisely identified at the time of initial diagnosis. Examples include follow-up appointments for contusions, lacerations, or other non-specific trauma to both lungs.

• Ensure documentation clearly indicates a bilateral lung injury and that the encounter is not the initial treatment.
• Avoid using this code if a more specific diagnosis for the lung injury is available in the medical record.
• Always review the entire medical record to determine if a more precise code can be assigned.