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

This code signifies a penetrating injury to the left eyeball that has healed, but the patient is still experiencing residual effects or complications from the initial trauma. It specifically excludes cases where a foreign object remains embedded within the globe. This diagnosis indicates a past injury with ongoing sequelae affecting the left eye.

Apply this code when documentation indicates a patient is presenting for treatment of a long-term complication or residual effect directly attributable to a past penetrating wound of the left eyeball, and no foreign body is currently present. Examples include chronic pain, vision impairment, or structural changes resulting from the initial injury. The medical record must clearly link the current condition to the historical penetrating trauma.

• Ensure the documentation explicitly states "sequela" or describes a chronic condition resulting from a past penetrating injury.
• Do not use this code for acute injuries; refer to the acute injury codes in the S05 category.
• Always sequence this code after the specific sequela or complication being treated (e.g., H54.42 for blindness in one eye, left eye).