Unspecified open wound of left shoulder, sequela

This code describes a long-term complication or late effect resulting from an open wound to the left shoulder. The original wound's specific nature (e.g., laceration, puncture) is not documented or is unknown, and the current clinical presentation is a residual condition directly attributable to that past injury.

Use this code when documenting a patient presenting with a sequela (e.g., scar tissue, chronic pain, functional limitation) of a previously sustained open wound to the left shoulder, and the specific type of original open wound is not specified in the medical record. This code is appropriate for encounters occurring long after the initial wound has healed.

• Always assign an additional code to describe the specific nature of the sequela (e.g., scar, chronic pain, nonunion).
• Ensure the medical record clearly indicates the current condition is a residual effect of a past open wound, not an acute injury.
• Verify laterality; this code is specific to the left shoulder.