Superior glenoid labrum lesion of unsp shoulder, sequela

This code signifies a superior glenoid labrum lesion, often referred to as a SLAP tear, affecting an unspecified shoulder. The "sequela" seventh character indicates that this diagnosis is a late effect or complication of an earlier injury or condition, rather than an acute event.

Use this code when documenting a chronic or residual superior labral tear of the shoulder, where the specific side (left or right) is not documented. This is appropriate for patients presenting with ongoing symptoms or complications from a previously sustained SLAP lesion.

• Ensure the medical record clearly supports the "sequela" designation, indicating a chronic or late effect.
• Avoid using this code if the laterality (left or right shoulder) is specified; instead, select the appropriate side-specific code.
• Always review the entire encounter documentation to confirm the chronicity and unspecified laterality before assigning this code.