Other sprain of unspecified shoulder joint, sequela

This code indicates a long-term or late-effect sprain of an unspecified shoulder joint, where the specific ligament or capsule involved is not documented. It signifies a residual condition or complication arising from an initial shoulder sprain that has since resolved.

Use this code when documenting a patient presenting with ongoing symptoms (e.g., pain, stiffness, instability) directly attributable to a previous shoulder sprain, and the specific shoulder involved is not specified. This applies to conditions that manifest after the acute phase of the original injury has passed.

• Always attempt to identify the specific shoulder (left or right) and the specific ligament/capsule involved for a more precise code.
• This code requires an associated external cause code (V00-Y99) to describe the original injury event, if known.
• Only use this code when the documentation clearly indicates a sequela and the specific shoulder is truly unspecified.