Unspecified superficial injury of scalp, sequela

This code signifies a long-term effect or complication arising from a superficial injury to the scalp, where the specific nature of the original injury is not documented. It indicates that the initial trauma has resolved, but residual issues related to that injury are still present.

Use this code when documentation clearly states a sequela (e.g., scar, chronic pain, nerve damage) resulting from a superficial scalp injury, but the precise type of superficial injury (e.g., abrasion, contusion) was never specified. This code is appropriate for encounters addressing the late effects of such an injury.

• Always use a seventh character 'S' for sequela when coding for late effects.
• Ensure documentation explicitly links the current condition to a previous superficial scalp injury.
• Avoid using this code if the specific type of superficial injury (e.g., abrasion, contusion) is known and documented, even if it's a sequela; in such cases, use the specific superficial injury code with the 'S' seventh character.