Injury of optic tract and pathways, unsp side, sequela

This code signifies a long-term consequence or complication resulting from a past injury to the optic tract or pathways, where the specific side of the injury is not documented. It indicates that the initial acute injury has resolved, but residual effects persist.

Apply this code when documentation clearly indicates a sequela (e.g., chronic visual field defect, persistent blindness, or other neurological deficit) directly attributable to a previous injury of the optic tract or pathways. The medical record must specify that the current condition is a late effect of an earlier injury and that the side is unspecified.

• Always use this code with an additional code identifying the specific sequela (e.g., H53.4x for visual field defects).
• Ensure documentation explicitly states "sequela," "late effect," or similar terminology linking the current condition to a past injury.
• Avoid using this code for acute injuries; instead, use the appropriate acute injury code from the S04.03 series without the "S" seventh character.