Injury of oculomotor nerve, right side, subsequent encounter

This diagnosis code signifies a traumatic injury to the right oculomotor nerve (cranial nerve III) that is being treated during a subsequent encounter. Such an injury can lead to impaired eye movement, ptosis (drooping eyelid), and pupillary abnormalities on the affected side.

This code is appropriate for follow-up visits, rehabilitation sessions, or ongoing management of a previously diagnosed right oculomotor nerve injury. Documentation should clearly indicate the right side of involvement, the traumatic etiology, and that the patient is beyond the initial active treatment phase.

• Ensure documentation specifies "right side" for laterality; otherwise, an unspecified laterality code may be more appropriate.
• Verify the encounter type is "subsequent" (D) and not initial (A) or sequela (S).
• Always code the underlying cause of the injury (e.g., fracture, open wound) if applicable and still being treated.