Injury of oculomotor nerve, left side, subsequent encounter

This code signifies a traumatic injury to the left oculomotor nerve (cranial nerve III) that is being treated during a subsequent encounter. This nerve is responsible for most eye movements, pupillary constriction, and eyelid elevation. Injury can result in ophthalmoplegia, ptosis, and mydriasis.

Apply this code for follow-up care of a patient diagnosed with a left oculomotor nerve injury due to trauma, such as during physical therapy, medication management, or ongoing monitoring after initial treatment. Documentation should clearly indicate the left side, the traumatic etiology, and that the encounter is not for the initial acute treatment.

• Ensure documentation specifies "left side" and a traumatic cause; otherwise, an unspecified or non-traumatic code may be more appropriate.
• The "D" seventh character indicates a subsequent encounter for healing or recovery, not the initial treatment or sequelae.
• Distinguish from S04.11XA (initial encounter) and S04.11XS (sequela) based on the phase of care.