Unsp opn wnd abd wall, r upper q w/o penet perit cav, sqla

This code signifies a healing or healed open wound of the right upper abdominal wall that did not extend into the peritoneal cavity. It indicates that the patient is experiencing a late effect or complication from a previous injury to this specific area.

Apply this code for follow-up encounters where a patient presents with a complication or residual effect directly attributable to a past open wound of the right upper abdominal wall. Examples include scar tissue pain, adhesions, or other long-term sequelae after the initial wound has closed.

• Always assign an external cause code (V, W, X, Y category) to describe the original injury.
• Ensure the documentation clearly states the wound is of the right upper quadrant and did not penetrate the peritoneal cavity.
• Use this code for the sequela, not for the initial acute injury or for ongoing treatment of an active, unhealed wound.