Injury of trigeminal nerve, right side, initial encounter

This code signifies damage to the right trigeminal nerve, which is responsible for sensation in the face, mastication, and some motor functions. Such an injury can result in facial pain, numbness, or weakness on the right side. This specific code indicates the initial treatment or evaluation for this nerve injury.

Apply this code when documentation clearly states an injury to the right trigeminal nerve, and the patient is receiving active treatment for the acute phase of the injury. Supporting documentation would include physician notes detailing the mechanism of injury, neurological examination findings confirming right trigeminal nerve involvement, and the initial treatment plan.

• Ensure laterality (right side) is explicitly documented.
• Verify that the encounter is indeed the "initial encounter" for this specific injury; subsequent encounters will require different seventh characters.
• Code any associated external cause of injury (e.g., fall, assault) in addition to this diagnosis code.