Sprain of unspecified acromioclavicular joint, sequela

This code signifies a sprain of the acromioclavicular (AC) joint, where the specific side (left or right) is not documented, and the injury is now considered a sequela. A sequela indicates a late effect or residual condition of an earlier injury or disease, meaning the acute phase of the sprain has passed, and the patient is experiencing ongoing problems related to it.

Use this code when a patient presents with chronic pain, limited range of motion, or other persistent symptoms directly attributable to a past AC joint sprain, and the medical record does not specify which shoulder was affected. This is appropriate for follow-up visits addressing the long-term consequences of the initial injury.

• Always attempt to clarify the affected side (left or right) with the provider to use a more specific code if possible.
• Ensure documentation clearly links the current symptoms to a previous AC joint sprain and indicates the acute phase has resolved.
• This code requires an additional code to describe the specific sequela, such as chronic pain or instability.