Unspecified superficial injury of right great toe, sequela

This code signifies a lasting effect or complication from a superficial injury to the right great toe, where the specific nature of the original injury is not documented. It indicates that the patient is currently experiencing a residual issue directly attributable to a past, unspecified minor trauma to this digit.

Apply this code when a patient presents with a chronic or long-term symptom (e.g., persistent pain, scar tissue, altered sensation) on their right great toe, and the medical record clearly links it to a previous superficial injury whose exact type (e.g., abrasion, contusion) was not specified. This code is appropriate for follow-up encounters addressing these lingering effects, not the initial injury itself.

• Always ensure documentation explicitly states the condition is a sequela of a past injury.
• Only use this code when the specific type of superficial injury is truly unknown or unrecorded.
• Verify the laterality (right) and anatomical site (great toe) are accurately documented.