Sprain of unspecified coracohumeral (ligament), sequela

This code signifies a past injury to the coracohumeral ligament, a key structure in the shoulder joint, where the specific side (left or right) of the body is not documented. The "sequela" indicates that this is a late effect or complication of the initial sprain, meaning the patient is still experiencing symptoms or issues related to the old injury.

Use this code when a patient presents with ongoing symptoms (e.g., chronic pain, stiffness, limited range of motion) directly attributable to a previously sustained, but unspecified, coracohumeral ligament sprain. This code is appropriate when the initial injury occurred in the past and the current encounter addresses its long-term consequences, and the laterality of the original injury is not specified in the medical record.

• Always ensure documentation clearly links current symptoms to a past coracohumeral ligament sprain.
• Only use this code when the specific side (left or right) of the injury is not documented. If laterality is known, use the more specific sequela code.
• This code should be used as a secondary diagnosis, following the code for the current symptom or condition being treated.