Injury of abducent nerve, unspecified side, sequela

This code describes a permanent or long-term neurological deficit resulting from a past injury to the abducens nerve (cranial nerve VI). This nerve is responsible for the lateral movement of the eye. Sequelae can include persistent diplopia, strabismus, or limited abduction of the affected eye.

Use this code when documenting a residual condition directly attributable to a previous abducens nerve injury, after the acute phase of the injury has passed. Documentation should clearly state the causal link between the prior injury and the current neurological deficit, and specify that the side is unknown or not documented. This code is appropriate for follow-up care or management of chronic symptoms.

• Always sequence the sequela code first, followed by codes for the specific manifestations of the sequela (e.g., diplopia, strabismus).
• Ensure documentation explicitly states "sequela" or indicates a chronic, residual effect of a past injury.
• Avoid using this code for acute abducens nerve injuries; instead, use the acute injury codes (S04.4- without the "S" seventh character).