Penetrating wound w foreign body of right eyeball, sequela

This code signifies a past injury to the right eye where a foreign object pierced the eyeball, and the patient is now experiencing a long-term complication or residual effect from that original trauma. It indicates that the initial acute injury has resolved, but its consequences persist.

Apply this code when documentation clearly states a patient is presenting for treatment or evaluation of a sequela (e.g., vision impairment, chronic pain, scarring, glaucoma) directly resulting from a previous penetrating foreign body injury to the right eyeball. The medical record must confirm the original injury occurred in the past and the current condition is a direct consequence.

• Requires a seventh character "S" to indicate sequela, meaning the current encounter is for a complication or residual effect of the original injury.
• Always sequence this code first when the sequela is the primary reason for the encounter, followed by codes for the specific sequela (e.g., H54.x for vision loss, H40.x for glaucoma).
• Do not use for acute injuries; refer to codes without the "S" seventh character for current penetrating wounds.