Other specified injury of muscle and tendon of head, sequela

This code signifies a long-term consequence or late effect of a previous injury to the muscles or tendons of the head, excluding those specifically classified elsewhere. It applies when the initial acute injury has resolved, but residual symptoms or conditions related to that injury persist.

Use this code for patients presenting with chronic pain, limited range of motion, weakness, or other persistent functional deficits in the head's musculature or tendons, directly attributable to a past injury. Documentation should clearly state the sequela and link it to a prior head muscle/tendon trauma.

• Always sequence the sequela code first, followed by a code identifying the specific residual condition (e.g., chronic pain, muscle weakness).
• Ensure the medical record explicitly states "sequela," "late effect," or indicates a chronic condition resulting from a previous injury.
• Distinguish from acute injuries (S09.19XA) or subsequent encounters for routine healing (S09.19XD) of the initial injury.