Injury of trigeminal nerve, unspecified side, sequela

This code signifies a long-term complication or late effect resulting from a past injury to the trigeminal nerve. The trigeminal nerve is responsible for sensation in the face and motor functions like chewing. "Sequela" indicates that the acute phase of the injury has passed, and the patient is now experiencing residual symptoms or deficits.

Use this code when documentation clearly states a current condition is a direct consequence of a previous trigeminal nerve injury, and the specific side (left or right) is not documented. This is appropriate for chronic pain, numbness, or motor weakness in the facial region attributed to an old injury. The medical record should specify "sequela" or "late effect" of a trigeminal nerve injury.

• Always sequence the sequela code first, followed by codes for the specific residual condition(s) (e.g., chronic facial pain).
• Ensure the documentation explicitly links the current symptoms to a past trigeminal nerve injury, not an acute one.
• Avoid using this code if the laterality (left or right) of the trigeminal nerve injury is specified; instead, use S04.31XS or S04.32XS.