Unspecified superficial injury of right upper arm, sequela

This code signifies a superficial injury to the right upper arm where the specific nature of the injury (e.g., abrasion, contusion, blister) is not documented. The "S" seventh character indicates that this encounter is for sequelae, meaning the patient is presenting for complications or conditions arising from the initial injury, not the initial active treatment.

This code is appropriate when a patient presents with a long-term effect or complication of a previously sustained, unspecified superficial injury to the right upper arm. Examples include scar tissue formation, chronic pain, or limited range of motion directly attributable to the past injury. It should not be used for the initial treatment of the acute injury.

• Ensure documentation clearly supports a sequela encounter, not an active treatment for an acute injury.
• Always look for more specific codes if the type of superficial injury (e.g., abrasion, contusion) is documented.
• Verify the laterality (right arm) and body region (upper arm) are accurately reflected in the medical record.