Injury of abducent nerve, unspecified side, subs encntr

This code signifies damage to the sixth cranial nerve, which controls the lateral rectus muscle responsible for outward eye movement. An injury to this nerve typically results in diplopia (double vision) and esotropia (inward turning of the eye) due to impaired abduction. This specific code indicates the later phase of treatment for such an injury, where the patient is receiving follow-up care.

Apply this code for encounters following the initial treatment of an abducent nerve injury, such as during rehabilitation, medication adjustments, or monitoring for recovery. Documentation should clearly indicate that the patient is in the healing or recovery phase, not the acute phase of the injury, and specify "unspecified side" if the laterality is not documented.

• Ensure documentation specifies "subsequent encounter" and that the injury is to the abducent nerve.
• Do not use for initial treatment; refer to acute injury codes (e.g., S04.40XA).
• Verify laterality if available; codes for right (S04.41XD) or left (S04.42XD) abducent nerve injury are more specific.