Unspecified sprain of right shoulder joint, sequela

This code indicates a past, unresolved sprain of the right shoulder joint where the specific ligament or structure injured was not documented. The "sequela" designation signifies that this sprain is no longer an acute injury but rather a residual condition or complication arising from the initial sprain.

Use this code when documenting a patient presenting with ongoing symptoms (e.g., pain, limited range of motion, instability) in the right shoulder that are directly attributable to a previously sustained, unspecified sprain. This applies when the original injury has healed, but its lasting effects are still being treated or evaluated.

• Always attempt to code to a more specific sprain (e.g., S43.421S for rotator cuff sprain) if documentation allows.
• Ensure the medical record clearly supports the "sequela" designation, indicating the current encounter is for a residual condition.
• Do not use this code for an acute or initial injury; instead, select an appropriate acute sprain code.