Puncture wound w/o foreign body of right shoulder, sequela

This code signifies a puncture wound to the right shoulder that did not involve a foreign object, and the current encounter is for a sequela or late effect of that original injury. This means the initial acute injury has healed, but the patient is now experiencing a complication or residual condition directly resulting from the previous puncture wound.

Use this code when documenting treatment for long-term issues such as chronic pain, scar tissue complications, nerve damage, or restricted range of motion in the right shoulder, all stemming from a past puncture wound. It is appropriate when the original wound is no longer acute and the focus of care is on the lasting consequences.

• Always sequence this code after the code describing the specific sequela (e.g., chronic pain, scar contracture).
• Ensure documentation clearly links the current condition to a previously sustained puncture wound of the right shoulder.
• Verify that no foreign body was present in the original puncture wound, as this would necessitate a different code.