Unsp injury of shoulder and upper arm, unsp arm, sequela

This code signifies a lasting effect or complication resulting from an injury to the shoulder or upper arm, where the specific nature of the original injury and the affected arm are not documented. It indicates a chronic or residual issue stemming from a past, undefined trauma to this anatomical region.

Use this code when a patient presents with a sequela (e.g., chronic pain, limited range of motion, weakness) of a shoulder or upper arm injury, but the medical record lacks details about the specific type of injury (e.g., fracture, sprain, dislocation) and which arm was affected. This code is appropriate when the initial injury occurred in the past and is no longer acute, and the current encounter addresses its long-term consequences.

• Always strive for a more specific code if the type of injury and affected arm are documented.
• This code should only be used when documentation explicitly states "sequela" or indicates a chronic condition resulting from a past injury.
• Ensure the "S" seventh character is used for sequela, indicating a complication or condition arising as a direct result of a previous injury.