Penetrating wound w/o foreign body of right eyeball, sequela

This code signifies a long-term complication or late effect resulting from a penetrating injury to the right eyeball that did not involve a foreign object. This could include conditions such as retinal detachment, glaucoma, or cataracts that developed as a direct consequence of the initial trauma. The "S" in the 7th character indicates that this is a sequela, meaning the initial injury has healed, but its lasting effects are now being treated.

Apply this code when documenting the treatment of a chronic condition or late complication directly attributable to a past penetrating injury of the right eyeball, where no foreign body was retained. Documentation should clearly link the current ocular pathology to the previous penetrating trauma and specify that the initial injury has resolved. This code is appropriate when the patient is no longer in the acute phase of injury.

• Always sequence the sequela code first, followed by codes for the specific manifestation of the sequela (e.g., glaucoma, retinal detachment).
• Ensure documentation explicitly states the injury was "without foreign body" to avoid confusion with codes in the S05.5- category.
• Verify laterality (right eye) is clearly documented to support the use of this specific code.