Unspecified superficial injury of right lower leg, sequela

This code signifies a superficial injury to the right lower leg where the specific nature of the injury (e.g., abrasion, blister, contusion) is not documented. The "S" at the end indicates that this is a sequela, meaning it's a complication or residual effect of an earlier acute injury, not the initial acute injury itself.

Use this code when documenting a follow-up encounter for a long-term effect or complication of a superficial injury to the right lower leg, and the original injury type is unspecified. This is appropriate for chronic pain, scarring, or other persistent issues directly attributable to a past superficial injury.

• Ensure the medical record clearly supports the "sequela" designation; otherwise, an acute injury code should be used.
• Always attempt to find a more specific code for the type of superficial injury if documented (e.g., abrasion, blister).
• Pair this diagnosis with an external cause code (V00-Y99) if the original cause of the injury is known and relevant to the sequela.