Injury of abducent nerve, right side, subsequent encounter

This code signifies damage to the right abducens nerve (cranial nerve VI) that is being treated during a follow-up visit after the initial injury. This nerve is responsible for controlling the lateral rectus muscle, which moves the eye outward. Injury typically results in diplopia (double vision) and esotropia (inward turning of the eye) due to impaired abduction of the right eye.

Use this code for patients presenting for ongoing management, rehabilitation, or evaluation of complications related to a previously diagnosed right abducens nerve injury. Documentation should clearly indicate that the encounter is not for the initial treatment of the acute injury, but rather for subsequent care. Examples include follow-up appointments for monitoring recovery, adjusting treatment, or assessing persistent symptoms.

• Ensure documentation specifies "right side" and that the encounter is for subsequent care, not the initial injury.
• Distinguish from initial encounters (S04.41XA) and sequela (S04.41XS) of the injury.
• Always code an external cause code (e.g., W00-Y38) in conjunction with this injury code to describe the circumstances of the injury.